Preventable diseases

Q

PREVENTABLE DISEASES

'

H

PREVENTABLE
DISEASES

BY

WOODS HUTCHINSON, A.M., M.D,

Author of " Studies in Human and Comparative Pathology,"
"Instinct and Health," etc., etc. Clinical Professor of
Medicine, New York Polyclinic, late Lecturer in
Comparative Pathology, London Medical Grad-
uates College and University of Buffalo

BOSTON AND NEW YORK
HOUGHTON MIFFLIN COMPANY
Cambri&0e t

COPYRIGHT, 1907, 1908 AND 1909, BY THE CURTIS PUBLISHING COMPANY
COPYRIGHT, 1909, BY WOODS HUTCHINSON

ALL RIGHTS RESERVED

Published November IQOQ

CONTENTS

I. The Body-Republic and its Defense 1

II. Our Legacy of Health : the Power of Heredity

in the Prevention of Disease 31

III. The Physiognpmy of Disease: what a Doctor

can tell from Appearances 55

IV. Colds and how to catch Them 83

V. Adenoids, or Mouth-Breathing: their Cause

and their Consequences 103

VI. Tuberculosis, a Scotched Snake. I 123

VII. Tuberculosis, a Scotched Snake, n 140

VIII. The Unchecked Great Scourge: Pneumonia 174

IX. The Natural History of Typhoid Fever 198

X. Diphtheria: the Modern Moloch 222

XI. The Herods of Our Day: Scarlet Fever,

Measles, and Whooping- Cough 243

XII. Appendicitis, or Nature's Remnant Sale 267

vi CONTENTS

XIII. Malaria: the Pestilence that walketh in Dark-

ness; the greatest Foe of the Pioneer 289

XIV. Rheumatism: what it Is, and particularly

what it Is n't 311

XV. Germ-Foes that follow the Knife, or Death

under the Finger-Nail 331

XVI. Cancer, or Treason in the Body-State 350

XVII. Headache: the most useful Pain in the World 367

XVIII. Nerves and Nervousness 387

XIX. Mental Influence in Disease, or how the Mind

affects the Body 411

Index 439

PREVENTABLE DISEASES

'

PEEVENTABLE DISEASES

CHAPTER I

THE BODY-REPUBLIC AND ITS DEFENSE

r I THE human body as a mechanism is far from per-
_1_ feet. It can be beaten or surpassed at almost
every point by some product of the machine-shop or
some animal. It does almost nothing perfectly or with
absolute precision. As Huxley most unexpectedly
remarked a score of years ago, " If a manufacturer of
optical instruments were to hand us for laboratory use
an instrument so full of defects and imperfections as
the human eye, we should promptly decline to accept
it and return it to him. But," as he went on to say,
" while the eye is inaccurate as a microscope, imperfect
as a telescope, crude as a photographic camera, it is all
of these in one." In other words, like the body, while it
does nothing accurately and perfectly, it does a dozen
different things well enough for practical purposes. It
has the crowning merit, which overbalances all these
minor defects, of being able to adapt itself to almost
every conceivable change of circumstances.

This is the keynote of the surviving power of the
human species. It is not enough that the body should
be prepared to do good work under ordinary conditions,

2 PREVENTABLE DISEASES

but it must be capable, if needs be, of meeting extraor-
dinary ones. It is' not enough for the body to be able
to take care of itself, and preserve a fair degree of effi-
ciency in health, under what might be termed favorable
or average circumstances, but it must also be prepared
to protect itself and regain its balance in disease.

The human automobile in its million-year endurance-
run has had to learn to become self -repairing ; and well
has it learned its lesson. Not only, in the language of the
old saw, is there ' ' a remedy for every evil under the sun,"
but in at least eight cases out of ten that remedy will be
found within the body itself. Generations ago this self-
balancing, self-repairing power was recognized by the
more thoughtful fathers in medicine and even dignified
by a name in their pompous Latinity — the vis medica-
trix natures, the healing power of nature.

In the new conception of disease, our drugs, our
tonics, our prescriptions and treatments, are simply
means of rousing this force into activity, assisting its
operations, or removing obstacles in its way. This
remedial power does not imply any gift of prophecy on
nature's part, nor is it proof of design, or beneficent
intention. It is rather one of those blind reactions to
certain stimuli, tending to restore the balance of the
organism, much as that interesting, new scientific toy,
the gyroscope car, will respond to pressure exerted or
weight placed upon one side by rising on that side,
instead of tipping over. Let the onslaught of disease
be sufficiently violent and unexpected, and nature will
fail to respond in any way.

Moreover, we and our intelligences are a product of

THE BODY-REPUBLIC 3

nature and a part of her remedial powers. So there is
nothing in the slightest degree irrational or inconsistent
in our attempting to assist in the process.

However, a great, broad, consoling and fundamental
fact remains : that in a vast majority of diseases which
attack humanity, under ninety per cent of the unfa-
vorable influences which affect us, nature will effect a
cure if not too much interfered with. As the old proverb
has it, " A man at forty is either a fool or a physician " ;
and nature is a good deal over forty and has never been
accused of lacking intelligence.

In the first place, nature must have acquired a fair
knowledge of practical medicine, or at least a good
working basis for it, from the fact that the body, in the
natural processes of growth and activity, is perpetually
manufacturing poisons for its own tissues.

In this age of sanitary reform, we are painfully aware
that the most frequent causes of human disease are the
accumulations about us of the waste products of our
own kitchens, barns, and factories. The "bad air"
which we hear so frequently and justly denounced as a
cause of disease, is air which we have ourselves polluted.
This same process has been going on within the body
for millions of years. No sooner did three or four cells
begin to cling together, to form an organism, a body,
than the waste products of the cells in the interior of the
group began to form a source of danger for the others.
If some means of getting rid of these could not be de-
vised, the group would destroy itself, and the experi-
ment of cooperation, of colony-formation, of organiza-
tion in fact, would be a failure.

4 PREVENTABLE DISEASES

Hence, at a very early period we find the development
of the rudiments of systems of body-sewerage, pro-
viding for the escape of waste poisons through the
food-tube, through the kidneys, through the gills and
lungs, through the sweat glands of the skin. So that
when the body is confronted by actual disease, it has all
ready to its hand a remarkably effective and resource-
ful system of sanitary appliances — sewer-flushing,
garbage-burning, filtration. In fact, this is precisely
what it does when attacked by poisons from without :
it neutralizes and eliminates them by the same meth-
ods which it has been practicing for millions of years
against poisons from within.

Take, for instance, such a painfully familiar and
unheroic episode as an attack of colic. It makes little
difference whether the attack is due to the swallowing
of some mineral poison, like lead or arsenic, or the ir-
ritating juice of some poisonous plant or herb, or to the
every-day accident of including in the menu some
article of diet which was beginning to spoil or decay,
and which contained the bacteria of putrefaction or
their poisonous products. The reaction of defense is
practically the same, varying only with the violence and
the character of the poison. If the dose of poisonous
substances be unusually large or virulent, nature may
short-circuit the whole attack by causing the outraged
stomach to reject its contents. The power of " playing
Jonah" is a wonderful safety-valve.

If the poison be not sufficiently irritating thus to
short-circuit its own career, it may get on into the
intestines before the body thoroughly wakes up to its

THE BODY-REPUBLIC 5

presence. This part of the food-tube being naturally
geared to discharge its contents downward, the simplest
and easiest thing is to turn in a hurry call and cut down
the normal schedule from hours to minutes, with the
familiar result of an acute diarrhoea.

Both vomiting and purging are defensive actions on
nature's part, remedies instead of diseases. Yet we are
continually regarding and treating them as if they were
diseases in themselves. Nothing could be more irra-
tional than to stop a diarrhoea before it has accom-
plished its purpose. Intelligent physicians now assist
it instead of trying to check it in its early stages ; and
paradoxical as it may sound, laxatives are often the
best means of stopping it. It is only the excess of this
form of nature's house-cleaning which needs to be
checked. Many of the popular Colic Cures, Pain-
Relievers, and "Summer Cordials" contain opium
which, while it relieves the pain and stops the discharge,
simply locks up in the system the very poisons which it
was trying to get rid of. Laxatives, intestinal antisep-
tics, and bowel irrigations have almost taken the place
of opiates in the treatment of these conditions in modern
medicine. We try to help nature instead of thwarting
her.

Supposing that the poison be of more insidious form,
a germ or a ptomaine, for instance, which slips past
these outer " firing-out " defenses of the food-tube and
arouses no suspicion of its presence until it has been
partially digested and absorbed into the blood. Again,
resourceful nature is ready with another line of de-
fense. It was for a long time a puzzle why every drop

6 PREVENTABLE DISEASES

of the blood containing food and its products absorbed
from the alimentary food-canal had to be carried, often
by a most roundabout course, to and through the liver,
before it could reach any part of the general system.
Here was the largest and most striking organ in the
body, and it was as puzzling as it was large. We knew
in some crude way that it " made blood," that it pre-
pared the food-products for use by the body-cells, and
that it secreted the bile; but this latter secretion had
little real digestive value, and the other changes seemed
hardly important enough to demand that every drop
of the blood coming from the food-tube should pass
through this custom-house. Now, however, we know
that in addition to its other actions, the liver is a great
poison-sponge or toxin-filter, for straining out of the
blood poisonous or injurious materials absorbed from
the food, and converting them into harmless substances.
It is astonishing what a quantity of these poisons,
whether from the food or from germs swallowed with
it, the liver is capable of dealing with — destroying
them, converting them, and acting as an absolute bar-
rier to their passage into the general system. But
sometimes it is overwhelmed by appalling odds ; some
of the invaders slip through its lines into the general
circulation, producing headache, backache, fever, and
a "dark-brown taste in the mouth"; and, behold, we
are bilious, and proceed to blame the poor liver. We
used to pour in remedies to "stir it up," to "work on
it" — which was about as rational as whipping a horse
when he is down, instead of cutting his harness or
taking his load off. Nowadays we stop the supply of

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further food-poisons by stopping eating, assist nature
in sweeping out or neutralizing the enemies that are
still in the alimentary canal, flush the body with pure
water, put it at rest — and trust the liver. Biliousness
is a sign of an overworked liver. If it was n't work-
ing at all, we should n't be bilious : we should be dead,
or in a state of collapse.

Moral : Don't rush for some remedy with which to
club into insensibility every symptom of disease as soon
as it puts in an appearance. Give nature a little chance
to show what she intends to do before attempting to
stop her by dosing yourself with some pain-reliever
or colic cure. Don't trdst her too blindly, for the best
of things may become bad in extremes, and the body
may become so panic-stricken as to keep on throwing
overboard, not merely the poisons, but its necessary
daily food, if the process be allowed to continue too long.

This is where the doctor comes in. This is the point
at which it takes brains to succeed in the treatment of
disease — to decide just how far nature knows what
she is doing, even in her most violent expulsive methods,
and is to be helped ; and just when she has lost her
head, or got into a bad habit, and must be thwarted.
This much we feel sure of, and it is one of the keynotes
of the attitude of modern medicine, that a large ma-
jority of the symptoms of disease are really nature's
attempts to cure it.

This is admirably shown in our modern treatment
of fevers. These we now know to be due to the infec-
tion of the body by more or less definitely recognized
disease-germs or organisms. Fever is a complicated

8 PREVENTABLE DISEASES

process, and we are still in the dark upon many points
in regard to it, but we are coming more and more
firmly to the conclusion that most of its symptoms are a
part of, or at least incidents in, the fight of the body
against the invading army. The flushed and reddened
skin is due to the pumping of large quantities of blood
through its mesh, in order that the poisons may be
got rid of through the perspiration. The rapid pulse
shows the vigor with which the heart is driving the
blood around the body, to have its poisons neutral-
ized in the liver, burned up in the lungs, poured out
by the kidneys and the skin. The quickened breathing
is the putting on of more blast in the lung poison-
crematory. It is possible that even the rise of tempera-
ture has an injurious effect upon the invading germs
or assists the body in their destruction.

In the past we have blindly fought all of these symp-
toms. We shut our patients up in stove-heated rooms
with windows absolutely closed, for fear that they
would "catch cold." We took off the sheets and piled
blankets upon the bed, setting a special watch to see
that the wretched sufferer did not kick them off. We
discouraged the drinking of water and insisted on all
drinks that were taken being hot or lukewarm. Now-
adays all this is changed. We throw all the windows
wide-open, and even put our patients out of doors to
sleep in the open air, whether it be typhoid, tuberculo-
sis, or pneumonia; knowing that not only they will not
"catch cold," but that, as their hurried breathing in-
dicates, they need all the oxygen they can possibly get,
to burn up the poison poured out in the lungs and from

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the skin. We encourage the patient to drink all the
cool, pure water he will take, sometimes gallons in a
day, knowing that his thirst is an indication for flush-
ing and flooding all the great systems of the body
sewers. Instead of smothering him in blankets, we
put him into cold packs, or put him to soak in cool
water.

In short, we trust nature instead of defying her, co-
operate with her in place of fighting her, — and we
have cut down the death-rate of most fevers fifty to
seventy-five per cent already. Plenty of pure, cool
water internally, externally, and eternally, rest, fresh
air, and careful feeding, are the best febrifuges and
antipyretics known to modern medicine. All others are
frauds and simply smother a symptom without reliev-
ing its cause, with the exception of quinine in malaria,
mercury, and the various antitoxins in their appropriate
diseases, which act directly upon the invading organism.

Underneath all this storm and stress of the fever
paroxysm, nature is quietly at work elaborating her
antidote. In some marvelous fashion, which we do not
even yet fully understand, the cells of the body are
producing in ever-increasing quantities an antibody,
or antitoxin, which will unite with the toxin or poison
produced by the hostile germs and render it entirely
harmless. By a curious paradox of the process, it does
not kill the germs themselves. It may not even stop
their further multiplication. Indeed, it utilizes part
of their products in the formation of the antitoxin ; but
it domesticates them, as it were — turns them from
dangerous enemies into harmless guests.

10 PREVENTABLE DISEASES

The treaty between these germs and the body, how-
ever, is only of the "most-favored-nation" class; for
let these tamed and harmless friends of the family
escape and enter the body of another human being,
and they will attack it as virulently as ever.

Now, where and how did nature ever succeed in
getting the rehearsal and the practice necessary to
build up such an extraordinary and complicated system
of defense as this? Take your microscope and look
at a drop of fluid from the mouth, the gums, the throat,
the stomach, the bowels, and you will find it simply
swarming with bacteria, bacilli, and cocci, each species
of which numbers its billions. There are thirty- three
species which inhabit the mouth and gums alone ! We
are literally alive with them ; but most of them are ab-
solutely harmless, and some of them probably slightly
helpful in the processes of digestion. In fevers and
infections the body merely applies to disease-germs the
tricks which it has learned in domesticating these
millions of harmless vegetable inhabitants.

Still more curious — there is a distinct parallel be-
tween the method in which food-materials are split up
and prepared for assimilation by the body, and the
method adopted in breaking up and neutralizing the
toxins of disease-germs. It is now known that poisons
are formed in the process of digesting and absorbing
the simplest and most wholesome foods; and the liver
uses the skill which it has gained in dealing with these
"natural poisons " in disposing of the toxins of germs.

When a fever has run its course, as we now know
nearly all infections do, within periods ranging from

THE BODY-REPUBLIC 11

three or four days to as many weeks, it simply means
that it has taken the liver and the other police-cells
this length of time to handle the rioters and turn them
into peaceable and law-abiding, even though not well-
disposed citizens. In this process the forces of law and
order can be materially helped by skillful and intelli-
gent cooperation. But it takes brains to do it and avoid
doing more harm than good. It requires far more in-
telligence on the part of the doctor, the nurse, or the
mother, skillfully to help nature than it did blindly to
fight her.

This is what doctors and nurses are trained for now-
adays, and they are of 'use in the sickroom simply be-
cause they have devoted more time and money to the
study of these complicated processes than you have.
Don't imagine that calling in the doctor is going to
interfere with the natural course of the disease, or rob
the patient of some chance he might have had of re-
covering by himself. On the contrary, it will simply
give nature and the constitution of the patient a better
chance in the struggle, probably shorten it, and cer-
tainly make it less painful and distressing.

If these symptoms of the summer fevers and fluxes
are indicative of nature's attempts to cure, those of the
winter's coughs and colds are no less clearly so. As we
walk down the streets, we see staring at us in large
letters from a billboard, " Stop that Cough ! It is Killing
you /" Yet few things could be more obvious to even
the feeblest intelligence, than that this "killing" cough
is simply an attempt on the part of the body to expel
and get rid of irritating materials in the upper air-

12 PREVENTABLE DISEASES

passages. As long as your larynx and windpipe are
inflamed or tickled by disease-germs or other poisons,
your body will do its best to get rid of them by cough-
ing, or, if they swarm on the mucous membrane of the
nose, by sneezing. To attempt to stop either coughing
or sneezing without removing the cause is as irrational
as putting out a switch-light without closing the switch.
Though this, like other remedial processes, may go to
extremes and interfere with sleep, or upset the stomach,
within reasonable limits one of the best things to do
when you have a cold is to cough. When patients with
severe inflammations of the lungs become too weak or
too deeply narcotized to cough, then attacks of suffo-
cation from the accumulation of mucus in the air-tubes
are likely to occur at any time. Young children who
cannot cough properly, not having got the mechanism
properly organized as yet, have much greater difficulty
in keeping their bronchial tubes clear in bronchitis or
pneumonia than have grown-ups. Most colds are in-
fectious, like the fevers, and like them run their course,
after which the cough will subside along with the rest
of the symptoms. But simply stopping the cough won't
hasten the recovery. Most popular "Cough-Cures"
benumb the upper throat and stop the tickling;
smother the symptoms without touching the cause.
Many contain opium and thus load the system with
two poisons instead of one.

Lastly, in the realm of the nervous system, take that
commonest of all ills that afflict humanity — headache.
Surely, this is not a curative symptom or a blessing in
disguise, or, if so, it is exceedingly well disguised. And

THE BODY-REPUBLIC 13

yet it unquestionably has a preventive purpose and
meaning. Pain, wherever found, is nature's abrupt
command, "Halt!" her imperative order to stop.
When you have obeyed that command, you have taken
the most important single step towards the cure. A
headache always means something — overwork, under-
ventilation, eye-strain, underfeeding, infection. Some
error is being committed, some bad physical habit is
being dropped into. There are a dozen different reme-
dies that will stop the pain, from opium and chloroform
down to the coal-tar remedies (phenacetin, acetanilid,
etc.) and the bromides. But not one of them "cures,"
in the sense of doings anything toward removing the
cause. In fact, on the contrary they make the situation
worse by enabling the sufferer to keep right on repeat-
ing the bad habit, deprived of nature's warning of the
harm that he is doing to himself. As the penalties of
this continued law-breaking pile up, he requires larger
and larger doses of the deadening drug, until finally he
collapses, poisoned either by his own fatigue-products
or by the drugs which he has been taking to deaden
him against their effect.

In fine, follow nature's hints whenever she gives
them: treat pain by rest, infections by fresh air and
cleanliness, the digestive disturbances by avoiding their
cause and helping the food-tube to flush itself clean;
keep the skin clean, the muscles hard, and the stomach
well filled — and you will avoid nine-tenths of the
evils which threaten the race.

The essence of disease consists, not in either the kind
or the degree of the process concerned, but only in its

14 PREVENTABLE DISEASES

relations to the general balance of activities of the or-
ganism, to its " resulting in discomfort, inefficiency, or
danger," as one of our best-known definitions has it.
Disease, then, is not absolute, but purely relative ; there
is no single tissue-change, no group even of changes
or of symptoms, of which we can say, " This is essentially
morbid, this is everywhere and at all times disease."

Our attainment of any clear view of the essential
nature of disease was for a long time hindered, and is
even still to some degree clogged, by the standpoint
from which we necessarily approached and still ap-
proach it, not for the study of the disease itself, but for
the relief of its urgent symptoms. Disease presents
itself as an enemy to attack, in the concrete form of a
patient to be cured ; and our best efforts were for cen-
turies almost wasted in blind, and often irrational,
attempts to remove symptoms in the shortest possible
time, with the most powerful remedies at our disposal,
often without any adequate knowledge whatever of the
nature of the underlying condition whose symptoms
we were combating, or any suspicion that these might
be nature's means of relief, or that " haply we should
be found to fight against God." There was sadly too
much truth in Voltaire's bitter sneer, "Doctors pour
drugs of which they know little, into bodies of which
they know less"; and I fear the sting has not entirely
gone out of it even in this day of grace.

And yet, relative and non-essential as all our defi-
nitions now recognize disease to be, it is far enough
(God knows) from being a mere negative abstraction,
a colorless "error by defect." It has a ghastly indi-

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viduality and deadly concreteness, — nay, even a vindic-
tive aggressiveness, which have both fascinated and
terrorized the imagination of the race in all ages. From
the days of " the angel of the pestilence" to the coming
of the famine and the fever as unbidden guests into the
tent of Minnehaha ; from " the pestilence that walketh
in darkness" to the plague that still "stalks abroad"
in even the prosaic columns of our daily press, there
has been an irresistible impression, not merely of the
positiveness, but even of the personality of disease.
And no clear appreciation can possibly be had of our
modern and rational conceptions of disease without at
least a statement of the' earlier conceptions growing out
of this personifying tendency. Absurd as it may seem
now, it was the legitimate ancestor of modern patho-
geny, and still holds well-nigh undisputed sway over
the popular mind, and much more than could be de-
sired over that of the profession.

The earliest conception of disease of which we have
any record is, of course, the familiar Demon Theory.
This is simply a mental magnification of the painfully
personal, and even vindictive, impression produced
upon the mind of the savage by the ravages of disease.
And certainly we of the profession would be the last to
blame him for jumping to such a conclusion. Who
that has seen a fellow being quivering and chattering in
the chill-stage of a pernicious malarial seizure, or toss-
ing and raving in the delirium of fever, or threatening
to rupture his muscles and burst his eyes from their
sockets in the convulsions of tetanus or uraemia, can
wonder for a moment that the impression instinctively

16 PREVENTABLE DISEASES

arose in the untutored mind of the Ojibwa that the
sufferer was actually in the grasp, and trying to escape
from the clutch, of some malicious but invisible power ?
And from this conception the treatment logically fol-
lowed. The spirits which possessed the patient, al-
though invisible, were supposed to be of like passions
with ourselves, and to be affected by very similar in-
fluences; hence dances, terrific noises, beatings and
shakings of the unfortunate victim, and the adminis-
tration of bitter and nauseous messes, with the hope of
disgusting the demon with his quarters, were the chief
remedies resorted to. And while to-day such conceptions
and their resultant methods are simply grounds for
laughter, and we should probably resent the very sug-
gestion that there was any connection whatever be-
tween the Demon Theory and our present practice, yet,
unfortunately for our pride, the latter is not only the
direct lineal, historic descendant of the former, but
bears still abundant traces of its lowly origin. It will,
of course, be admitted at once that the ancestors of our
profession, historically, the earliest physicians, were
the priest, the Shaman, and the conjurer, who even to
this day in certain tribes bear the suggestive name of
"medicine men." Indeed, this grotesque individual
was neither priest nor physician, but the common
ancestor of both, and of the scientist as well. And, even
if the history of this actual ancestry were unknown,
there are scores of curious survivals in the medical
practice of this century, even of to-day, which testify
to the powerful influence of this conception.
The extraordinary and disgraceful prevalence of

THE BODY-REPUBLIC 17

bleeding scarcely fifty years ago, for instance; the
murderous doses of calomel and other violent purges ;
the indiscriminate use of powerful emetics like tartar
emetic and ipecac; the universal practice of starving
or " reducing" fevers by a diet of slops, were all obvious
survivals of the expulsion-of-the-demon theory of treat-
ment. Their chief virtue lay in their violence and re-
pulsiveness. Even to-day the tendency to regard mere
bitterness or distastefulness as a medicinal property
in itself has not entirely died out. This is the chief claim
of quassia, gentian, calumbo, and the "simple bitters"
generally, to a place in our official lists of remedies.
Even the great mineral-water fad, which continues to
flourish so vigorously, owed its origin to the superstition
that springs which bubbled or seethed were inhabited
by spirits (of which the "troubling of the waters" in
the Pool of Bethesda is a familiar illustration). The
bubble and (in both senses) " infernal" taste gave them
their reputation, the abundant use of pure spring water
both internally and externally works the cure, assisted
by the mountain air of the "Bad," and we sapiently
ascribe the credit to the salts. Nine-tenths of our cells
are still submarine organisms, and water is our greatest
panacea.

Then came the great "humoral" or "vital fluid"
theory of disease which ruled during the Middle' Ages.
According to this, all disease was due to the undue pre-
dominance in the body of one of the four great vital
fluids, — the bile, the blood, the nervous "fluid," and
the lymph, — and must be treated by administering
the remedy which will get rid of or counteract the excess

18 PREVENTABLE DISEASES

of the particular vital fluid in the system. The principal
traces of this belief are the superstition of the four
" temperaments," the bilious, the sanguine, the nervous,
and the lymphatic, and our pet term " biliousness," so
useful in explaining any obscure condition.

Last of all, in the fullness of time, — and an incredi-
bly late fullness it was, — under the great pioneer
Virchow, who died less than a decade ago, was de-
veloped the great cellular theory, a theory which has
done more to put disease upon a rational basis, to sub-
stitute logic for fancy, and accurate reasoning for wild
speculation, than almost any discovery since the dawn
of history. Its keynote simply is, that every disturbance
to which the body is liable can be ultimately traced to
some disturbance or disease of the vital activities of the
individual cells of which it is made up. The body is
conceived of as a cell-state or cell-republic, composed of
innumerable plastid citizens, and its government, both
in health and disease, is emphatically a government
"of the cells, by the cells, for the cells." At first these
cell-units were regarded simply as geographic sections,
as it were, sub-divisions of the tissues, bearing much
the same relation to the whole body as the bricks of the
wall do to the building, or, from a little broader view,
as the Hessians of a given regiment to the entire army.
They were merely the creatures of the organism as a
whole, its servants who lived but to obey its commands
and carry out its purposes, directed in purely arbitrary
and despotic fashion by the lordly brain and nerve-
ganglia, which again are directed by the mind, and that
again by a still higher power. In fact, they were re-

THE BODY-REPUBLIC 19

garded as, so to speak, individuals without personality,
mere slaves and helots under the ganglion-oligarchy
which was controlled by the tyrant mind, and he but
the mouthpiece of one of the Olympians. But time has
changed all that, and already the triumphs of demo-
cracy have been as signal in biology as they have been
in politics, and far more rapid. The sturdy little citi-
zen-cells have steadily but surely fought their way to
recognition as the controlling power of the entire body-
politic, have forced the ganglion-oligarchy to admit that
they are but delegates, and even the tyrant mind to
concede that he rules by their sufferance alone. His
power is mainly a vefb, and even that may be over-
ruled by the usual two-thirds vote.

In fact, if we dared to presume to criticise this mag-
nificent theory of disease, we would simply say that it is
not "cellular" enough, that it hardly as yet sufficiently
recognizes the individuality, the independence, the
power of initiative, of the single constituent cell. It is
still a little too apt to assume, because a cell has donned
a uniform and fallen into line with thousands of its
fellows to form a tissue in most respects of somewhat
lower rank than that originally possessed by it in its
free condition, that it has therefore surrendered all of
its rights and become a mere thing, a lever or a cog in
the great machine. Nothing could be further from the
truth, and I firmly believe that our clearest insight into
and firmest grasp upon the problems of pathology will
come from a recognition of the fact that, no matter how
stereotyped, or toil-worn, or even degraded, the indi-
vidual cells of any tissue may have become, they still

20 PREVENTABLE DISEASES

retain most of the rights and privileges which they
originally possessed in their free and imtrammeled
amoeboid stage, just as in the industrial community of
the world about us. And, although their industry in
behalf of and devotion to the welfare of the entire
organism is ever to be relied upon, and almost pathetic
in its intensity, yet it has its limits, and when these have
been transgressed they are as ready to " fight for their
own hand," regardless of previous conventional alle-
giance, as ever were any of their ancestors on seashore
or rivulet-marge. And such rebellions are our most
terrible disease-processes, cancer and sarcoma. More
than this : while, perhaps, in the majority of cases the
cell does yeoman service for the benefit of the body, in
consideration of the rations and fuel issued to it by the
latter, yet in many cases we have the curious, and at
first sight almost humiliating, position of the cell ab-
sorbing and digesting whatever is brought to it, and
only turning over the surplus or waste to the body.
It would almost seem as if our lordly Ego was living
upon the waste-products, or leavings, of the cells lining
its food-tube.

Let us take a brief glance at the various specializations
and trade developments, which have taken place in the
different groups of cells, and see to what extent the
profound modifications which many of them have
undergone are consistent with their individuality and
independence, and also whether such specialization
can be paralleled by actually separate and independ-
ent organisms existing in animal communities out-
side of the body. First of all, because furthest from

THE BODY-REPUBLIC 21

the type and degraded to the lowest level, we find the
great masses of tissue welded together by lime-salts,
which form the foundation masses, leverage-bars, and
protection plates for the higher tissues of the body.
Here the cells, in consideration of food, warmth, and
protection guaranteed to themselves and their heirs for
ever by the body-state, have, as it were, deliberately
surrendered their rights of volition, of movement, and
higher liberties generally, and transformed themselves
into masses of inorganic material by soaking every
thread of their tissues in lime-salts and burying them-
selves in a marble tomb. Like Esau, they have sold their
birthright for a mess 6f "potash," or rather lime; and
if such a class or caste could be invented in the external
industrial community, the labor problem and the ever-
occurring puzzle of the unemployed would be much
simplified. And yet, petrified and mummified as they
have become, they are still emphatically alive, and
upon the preservation of a fair degree of vigor in them
depends entirely the strength and resisting power of
the mass in which they are embedded, and of which
they form scarcely a third. Destroy the vitality of its
cells, and the rock-like bone will waste away before the
attack of the body-fluids like soft sandstone under the
elements. Shatter it, or twist it out of place, and it will
promptly repair itself, and to a remarkable degree
resume its original directions and proportions.

So little is this form of change inconsistent with the
preservation of individualism, that we actually find
outside of the body an exactly similar process, occurring
in individual and independent animals, in the familiar

22 PREVENTABLE DISEASES

drama of coral-building. The coral polyp saturates it-
self with the lime-salts of the sea-water, much as the
bone-corpuscles with those of the blood and lymph, and
thus protects itself in life and becomes the flying buttress
of a continent in death.

In the familiar connective-tissue, or "binding-stuff,"
we find a process similar in kind but differing in the
degree, so to speak, of its degradation.

The quivering responsiveness of the protoplasm of
the amoeboid ancestral cell has transformed itself into
tough, stringy bands and webs for the purpose of bind-
ing together the more delicate tissues of the body. It
has retained more of its rights and privileges, and con-
sequently possesses a greater amount of both biological
and pathological initiative. In many respects purely
mechanical in its function, fastening the muscles to the
bones, the bones to each other, giving toughness to the
great skin-sheet, and swinging in hammock-like mesh
the precious brain-cell or potent liver-lobule, it still
possesses and exercises for the benefit of the body con-
siderable powers of discretion and aggressive vital
action. Through its activity chiefly is carried out that
miracle of human physiology, the process of repair.
By the transformation of its protoplasm the surplus
food-materials of the times of plenty are stored away
within its cell-wall against the time of stress.

Whatever emergency may arise, nature, whatever
other forces she may be unable to send to the rescue, can
always depend upon the connective-tissues to meet it;
and, of course, as everywhere the medal of honor has
its reverse side, their power for evil is as distinguished

THE BODY-REPUBLIC 23

as their power for good. From their ranks are re-
cruited a whole army of those secessions from and re-
bellions against the body at large — the tumors, from
the treacherous and deadly sarcoma, or " soft cancer,"
to the harmless fatty tumor, as well as the tubercle,
the gumma of syphilis, the interstitial fibrosis of Bright's
disease. They are the sturdy farmers and ever ready
"minute-men" of the cell-republic, and we find their
prototype and parallel in the external world, both in
material structure and degree of vitality, in the well-
known sponge and its colonies.

Next in order, and, in fact, really forming a branch of
the last, we find the great group of storage-tissues, the
granaries or bankers of the body-politic, distinguished
primarily, like the capitalist class elsewhere, by an
inordinate appetite, not to say greed. They sweep into
their interior all the food-materials which are not ab-
solutely necessary for the performance of the vital func-
tion of the other cells. These they form first into pro-
toplasm, and then by a simple degenerative process it is
transformed, "boiled down" as it were, into a yellow
hydrocarbon which is capable of storage for practically
an indefinite period. Not a very exalted function, and
yet one of great importance to the welfare of the entire
body, for, like the Jews of the Middle Ages, the fat-
cells, possessing an extraordinary appetite for and
faculty of acquiring surplus wealth in times of plenty,
can easily be robbed of it and literally sucked dry in
times of scarcity by any other body-cell which happens
to need it, especially by the belligerent military class of
muscle-cells. In fever or famine, fat is the first element

24 PREVENTABLE DISEASES

of our body-mass to disappear ; so that Proudhon would
seem to have some biological basis for his demand for
the per capita division of the fortunes of millionaires.
And yet, rid the fat-cell of the weight of his sordid gains,
gaunt him down, as it were, like a hound for the wolf-
trail, and he becomes at once an active and aggressive
member of the binding-stuff group, ready for the repair
of a wound or the barring out of a tubercle-bacillus.

And this form of specialization has also its parallel
outside of the body in one of the classes in a community
of Mexican ants, whose most distinguishing feature is
an enormously distended oesophagus, capable of con-
taining nearly double the weight of the entire remainder
of the body. They are neither soldiers nor laborers,
but accompany the latter in their honey-gathering ex-
cursions, and as the spoils are collected they are lite-
rally packed full of the sweets by the workers. When
distended to their utmost capacity they fall apparently
into a semi-comatose condition, are carried into the
ant-hill, and hung up by the hind legs in a specially
prepared chamber, in which (we trust) enjoyable posi-
tion and state they are left until their contents are
needed for the purposes of the community, when they are
waked up, compelled to disgorge, and resume their ordi-
nary life activities until the next season's honey-gather-
ing begins. It scarcely need be pointed out what an un-
speakable boon to the easily discouraged and unlucky
the introduction of such a class as this into the human
industrial community would be, especially if this
method of storage could be employed for certain liquids.

Another most important class in the cell-community

THE BODY-REPUBLIC 25

is the great group of the blood-corpuscles, which in
some respects appear to maintain their independence
and freedom to a greater degree than almost any other
class which can be found in the body. While nearly all
other cells have become packed or felted together so as
to form a fixed and solid tissue, these still remain en-
tirely free and unattached. They float at large in the
blood-current, much as their original ancestor, the
amoeba, did in the water of the stagnant ditch. And,
curiously enough, the less numerous of the two great
classes, the white, or leucocytes, are in appearance,
structure, pseudopodic movements, and even method
of engulfing food, almost exact replicas of their most
primitive ancestor.

There is absolutely no fixed means of communication
between the blood-corpuscles and the rest of the body,
not even by the tiniest branch of the great nerve- tele-
graph system, and yet they are the most loyal and de-
voted class among all the citizens of the cell-republic.
They are called hither and thither partly by messenger-
substances thrown into the blood, known as hor-
mones, partly by the " smell of the battle afar off,"
the toxins of inflammation and infection as they pour
through the blood.

The red ones lose their nuclei, their individuality, in
order to become sponges, capable of saturating them-
selves with oxygen and carrying it to the gasping tissues.
The white are the great mounted police, the sanitary
patrol of the body. The moment that the alarm of in-
jury is sounded in a part, all the vessels leading to it
dilate, and their channels are crowded by swarms of the

26 PREVENTABLE DISEASES

red and white hurrying to the scene. The major part
of the activity of the red cells can be accounted for by
the mechanism of the heart and blood-vessels. They are
simply thrown there by the handful and the shovelful,
as it were, like so many pebbles or bits of chalk.

But the behavior of the white cells goes far beyond
this. We are almost tempted to endow them with
volition, though they are of course drawn or driven by
chemical and physical attractions, like iron-filings by a
magnet, or an acid by a base. Not only do all those
normally circulating in the blood flowing through the
injured part promptly stop and begin to scatter them-
selves through the underbrush and attack the foe at
close quarters, but, as has been shown by Cabot's
studies in leucocytosis, the moment that the red flag of
fever is hoisted, or the inflammation alarm is sounded,
the leucocytes come rushing out from their feeding-
grounds in the tissue-interspaces, in the lymph-chan-
nels, in the great serous cavities, and pour themselves
into the blood-stream, like minute-men leaving the
plough and thronging the highways leading towards
the frontier fortress which has been attacked. Arrived
at the spot, if there be little of the pomp and pageantry
of war in their movements, their practical devotion and
heroism are simply unsurpassed anywhere, even in
song and story. They never think of waiting for rein-
forcements or for orders from headquarters. They
know only one thing, and that is to fight; and when the
body has brought them to the spot, it has done all that
is needed, like the Turkish Government when once it
has got its sturdy peasantry upon the battlefield : they

THE BODY-REPUBLIC 27

have not even the sense to retreat. And whether they
be present in tens, or in scores, or in millions, each one
hurls himself upon the toxin or bacillus which stands
directly in front of him. If he can destroy the bacillus
and survive, so much the better; but if not, he will
simply overwhelm him by the weight of his body-mass,
and be swept on through the blood-stream into the great
body-sewers, with the still living bacillus literally buried
in his dead body. Like Arnold Winkelried, he will
make his body a sheath for a score of the enemy's
spears, so that his fellows can rush in through the gap
that he has made. And it makes no difference whatever
if the first ten or hundred or thousand are instantly
mowed down by the bacillus or its deadly toxins, the
rear ranks sweep forward without an instant's hesita-
tion, and pour on in a living torrent, like the Zulu impis
at Rorke's Drift, until the bacilli are battered down
by the sheer impact of the bodies of their assailants, or
smothered under the pile of their corpses, When this
has happened, in the language of the old surgeon-
philosophers, "suppuration is established," and the
patient is saved.

Or if, as often happens, an antitoxin is formed,
which protects the whole body, this is largely built out
of substances set free from the bodies of slain leucocytes.
And the only thing that dims our vision to the wonder
and beauty of this drama, is that it happens every day,
and we term it prosaically "the process of repair," and
expect it as a matter of course. Every wound-healing
is worthy of an epic, if we could only look at it from the
point of view of these citizens of our great cell-republic.

28 PREVENTABLE DISEASES

And if we were to ask the question, "Upon what does
their peculiar value to the body-politic depend?" we
should find that it was largely the extent to which they
retained their ancestral characteristics. They are born
in the lymph-nodes, which are simply little islands of
tissue of embryonic type, preserved in the body largely
for the purpose of breeding this primitive type of cells.
They are literally the Indian police, the scavengers, the
Hibernians, as it were, of the entire body. They have
the roving habits and fighting instincts of the savage.
They cruise about continually through the waterways
and marshes of the body, looking for trouble, and, like
their Hibernian descendants, wherever they see a head
they hit it. They are the incarnation of the fighting
spirit of our ancestors, and if it were not for their re-
tention of this characteristic in so high a degree, many
classes of our fixed cells would not have been able to
subside into such burgher-like habits.

Although even here, as we shall see, it is only a ques-
tion of quickness of response, for while the first bands
of the enemy may be held at bay by the leucocyte
cavalry, and a light attack repelled by their skirmish-
line, yet when it comes to the heavy fighting of a fever-
invasion, it is the slow but substantial burgher-like
fixed cells of the body which form the real infantry
masses of the campaign. And I believe that upon the
proportional relation between these primitive and civil-
ized cells of our body-politic will depend many of the
singular differences, not only in degree but also in kind,
in the immunity possessed by various individuals.
While some surgeons and anatomists will show a tern-

THE BODY-REPUBLIC 29

perature from the merest scratch, and yet either never
develop any serious infection or display very high re-
sisting power in the later stages, others, again, will
stand forty slight inoculations with absolute impunity,
and yet, when once the leucocyte-barrier is broken
down, will make apparently little resistance to a fatal
systemic infection. And this, of course, is only one of a
score of ways in which the leucocytes literally pro
patrin moriuntur. Our whole alimentary canal is con-
tinually patrolled by their squadrons, poured into it by
the tonsils above and Peyer's patches below ; if it were
not for them we should probably be poisoned by the
products of our own digestive processes.

If, then, the cells of the body-republic retain so much
of their independence and individuality in health, does
it not seem highly probable that they do also in disease ?
This is known to be the case already in many morbid
processes, and their number is being added to every
day. The normal activities of any cell carried to excess
may constitute disease, by disturbing the balance of the
organism. Nay, most disease-processes on careful
examination are found to be at bottom vital, often
normal to the cells concerned in them. The great
normal divisions of labor are paralleled by the great
processes of degeneration into fat, fibrous tissue, and
bone or chalk. A vital chemical change which would be
perfectly healthy in one tissue or organ, in another
may be fatal.

Ninety-nine times out of a hundred any group of
cells acts loyally in the interests of the body ; once in a
hundred some group acts against them, and for its own,

30 PREVENTABLE DISEASES

and disease is the result. There is a perpetual struggle
for survival going on between the different tissues and
organs of the body. Like all other free competition, as
a rule, it inures enormously to the benefit of the body-
whole. Exceptionally, however, it fails to do so, and
behold disease. This struggle and turmoil is not only
necessary to life — it is life. Out of the varying chances
of its warfare is born that incessant ebb and flow of
chemical change, that inability to reach an equilibrium,
which we term "vitality." The course of life, like
that of a flying express train, is not a perfectly straight
line, but an oscillating series of concentric curves.
Without these oscillations movement could not be.
Exaggerate one of them unduly, or fail to rectify it by
a rebound oscillation, and you have disease.

Or it is like the children's game of shuttlecock. So
long as the flying shuttle keeps moving in its restless
course to and fro, life is. A single stop is death. The
very same blow which, rightly placed, sends it like an
arrow to the safe centre of the opposing racket, if it fall
obliquely, or even with too great or too little force, drives
it perilously wide of its mark. It can recover the safe
track only by a sudden and often violent lunge of the
opposing racket. The straight course is life, the tangent
disease, the saving lunge recovery.

One and the same force produces all.

In the millions of tiny blows dealt every minute in
our body-battle, what wonder if some go wide of the
mark!

CHAPTER II

OUR LEGACY OF HEALTH I THE POWER OF HEREDITY
IN THE PREVENTION OF DISEASE

evil in things always bulks large in our imagi-
-L nations. It is no mere coincidence that the earli-
est gods of a race are invariably demons. Our first
conception of the great forces of nature is that they are
our enemies. This misconception is not only natural,
but even necessary on, the sternest of physical bases.
The old darky, Jim, in Huckleberry Finn, hit upon a
profound and far-reaching truth when he replied in
answer to Huck's question whether among all the signs
and portents with which his mind was crammed — like
black cats and seeing the moon over your left shoulder
and "harnts" —some were not indications of good
luck instead of all being of evil omen : —

" Mighty few — an' dey ain't no use to a body. What
fur you want to know when good luck 's a-comin'?
Want to keep it off?"

It is n't the good, either in the forces of nature or in
our fellows, that keeps us watchful, but the evil. Hence
our proneness to declare in all ages that evil is stronger
than good and that "all men are liars." One injury
done us by storm, by sunstroke, by lightning-flash, will
make a more lasting impression upon our memories
than a thousand benefits conferred by these same
forces. Besides, evil has to be sharply looked out for

32 PREVENTABLE DISEASES

and guarded against. Well enough can be safely let
alone.

The conviction is steadily growing, among both
physicians and biologists, that this attitude has caused
a serious, if not vital, misconception of the influence of
that great conservative and preservative force of na-
ture — heredity. We hear a great deal of hereditary
disease, hereditary defect, hereditary insanity, but very
little of hereditary powers of recovery, of inherited
vigor, and the fact that ninety-nine and seven-tenths
per cent of us are sane.

One instance of hereditary defect, of inherited degen-
eracy, fills us with horror and stirs us to move Heaven
and earth to prevent another such. The inheritance of
vigor, of healthfulness, and of sanity we placidly accept
as a matter of course and bank upon it in our plans for
the future, without so much as a thank you to the force
that underlies it.

When once we clear away these inherited misconcep-
tions and look the facts of the situation squarely in the
face, we find that heredity is at least ten times as potent
and as frequently concerned in the transmission and
securing of health and vigor as of disease and weakness ;
that its influence on the perpetuation of bodily and
mental defects has been enormously exaggerated and
that there are exceedingly few hereditary diseases.

It is not necessary for our present purpose to enter
into a discussion of the innumerable theories of that
inevitable tendency of like to beget like, of child to
resemble parent, which we call heredity. One reference,
however, may be permitted to the controversy that has

OUR LEGACY OF HEALTH 33

divided the scientific world : whether acquired charac-
ters, changes occurring during the lifetime of the in-
dividual, can be inherited. Disease is nine times out of
ten an acquired character ; hence, instead of the proba-
bilities being that it would be inherited, the balance of
evidence to date points in exactly the opposite direc-
tion. The burden of proof as to the inheritance of
disease is absolutely upon those who believe in its pos-
sibility.

Another fundamental fact which renders the inheri-
tance of disease upon a priori grounds improbable and
upon practical grounds obviously difficult, is that char-
acters or peculiarities, m order to be inherited certainly
for more than a few generations, must be beneficial
and helpful in the struggle. A moment's reflection will
show this to be mathematically necessary, in that any
family or race which tended to inherit defects and in-
jurious characters would rapidly go down in the strug-
gle for survival and become extinct. An inherited dis-
ease of any seriousness could not run for more than two
or three generations in any family, simply for the reason
that by the end of that time there would be no family
left for it to run in. A slight defect or small peculiarity
of undesirable character might run for a somewhat
longer period, but even this would tend toward dis-
appearance and elimination by the stern, selective
influence of environment.

Naturally, this great conservative tendency of na-
ture has, like all other influences, "the defects of its
virtues," as the French say. It has no gifts of prophecy,
and in the process of handing down to successive gener-

34 PREVENTABLE DISEASES

ations those mechanisms and powers which have been
found useful in the long, stern struggle of the past, it
will also hand down some which, by reason of changes
in the environment, are not only no longer useful, but
even injurious. As the new light of biology has been
turned on the human body and its diseases, it has re-
vealed so many of these " left-overs," or remnants in
the body-machine — some of most dramatic interest —
that they at first sight have done much to justify the
popular belief in the malignant tendencies of heredity.

Yet, broadly considered, the overwhelming majority
of them should really be regarded as honorable scars,
memorials of ancient victories, monuments to difficul-
ties overcome, significant and encouraging indications
of what our body-machine is still capable of accom-
plishing in the way of further adjustment to conditions
in the future. The really surprising thing is not their
number, but the infrequency with which they give rise
to serious trouble.

The human automobile is not only astonishingly well
built, with all the improvements that hundreds of thou-
sands of generations of experience have been able to
suggest, but it is self-repairing, self-cleaning, and self-
improving. It never lets itself get out of date. If only
given an adequate supply of fuel and water and not
driven too hard, it will stand an astonishing amount of
knocking about in all kinds of weather, repairing itself
and recharging its batteries every night, supplying its
own oil, its own paint and polish, and even regulating
its own changes of gear, according to the nature of the
work it has to do. Simply as an endurance racer it is the

OUR LEGACY OF HEALTH 35

toughest and longest-winded thing on earth and can run
down and tire out every paw, pad, or hoof that strikes
the ground — wolf, deer, horse, antelope, wild goat.
This is only a sample of its toughness and resisting
power all along the line.

These wide powers of self-support and adjustment
overbalance a hundred times any little remnant de-
fects in its machinery or gearing. Easily ninety-nine
per cent of all our troubles through life are due to in-
evitable wear and tear, scarcity of food-fuel, of water,
of rest, and external accidents — injuries and infectious
diseases. Still, it occasionally happens that these little
defects may furnish the point of least resistance at
which external stresses and strains will cause the
machine to break down. They are often the things
which prevent us from living and " going to pieces all at
once, all at once and nothing fust, just as bubbles do
when they bust," like the immortal One-Hoss Shay.
It is just as well that they should, for, of all deaths to
die, the loneliest and the most to be dreaded is that by
extreme old age.

These vestigia or remnants — instances of appar-
ently hidebound conservatism on nature's part — are
very much in the public eye at present, partly on ac-
count of their novelty and of their exceptional and
extraordinary character. Easily first among these
trouble-breeding remnants is that famous, or rather
notorious, scrap of intestine, the appendix vermiformis,
an obvious survival from that peaceful, ancestral period
when we were more largely herbivorous in our diet and
required a longer and more complicated food-tube, with

36 PREVENTABLE DISEASES

larger side pouches in the course of it, to dissolve and
absorb our food. Its present utility is just about that of
a grain of sand in the eye. Yet, considering that it is
present in every human being born into the world, the
really astonishing thing is not the frequency with which
it causes trouble, but the surprisingly small amount of
actual damage that arises from it. Never yet in even the
most appendicitis-ridden community has it been found
responsible for more than one half of one per cent of the
deaths.

Then there is that curious and by no means uncom-
mon tendency for a loop of the intestine to escape from
the abdominal cavity, which we call hernia. This is one
of a fair-sized group of dangers clearly due to the as-
sumption of the erect position and our incomplete ad-
justment thereto. In the quadrupedal position this
necessary weak spot — a partial opening through the
abdominal wall — was developed in that region which
was highest from the point of view of gravity and least
exposed to strain. In the bipedal position it becomes
lowest and most exposed ; hence the much greater fre-
quency of hernia in the human species as compared
with any of the animals.

Another fragment, of the impertinence of whose pres-
ence many of us have had painful proof, is the third or
last molar, so absurdly misnamed the wisdom tooth. If
there be any wisdom involved in its appearance it is of
the sort characterized by William Allen White's deli-
cious definition : " That type of ponderous folly of the
middle-aged which we term * mature judgment.' ' ' The
last is sometimes worst as well as best, and this belated

OUR LEGACY OF HEALTH 37

remnant is not only the last to appear, but the first to
disappear. In a considerable percentage of cases it is
situated so far back in the jaw that there is no room for
it to erupt properly, and it produces inflammatory dis-
turbances and painful pressure upon the nerves of the
face and the jaw.

Even when it does appear it is often imperfectly
developed, has fewer cusps and fewer roots than the
other molars, is imperfectly covered with enamel and
badly calcified. In no small percentage of cases it does
not meet its fellow of the jaw below and hence is almost
useless for purposes of mastication. But it comes in
every child born into the world, simply because at an
earlier day, when our jaws were longer — to give our
canine teeth the swing they needed as our chief weapons
of defense — there was plenty of room for it in the jaw
and it was of some service to the organism. If the
Indiana State Legislature would only pass a law pro-
hibiting the eruption of wisdom teeth in future, and
enforce it, it would save a large amount of suffering,
inconvenience, and discomfort, with little appreciable
lack of efficiency!

In this list of admitted charges against heredity must
also come the gall-bladder, that curious little pouch
budded out from the bile ducts, which has so little
known utility as compared with its possibility as a
starting-point for inflammations, gall-stones, and
cancer.

Then there is that disfiguring facial defect, harelip,
due to a failure of the three parts of which our upper
jaw is built to unite properly, — this triple construction

38 PREVENTABLE DISEASES

of the jaw being an echo of ancestral fishlike and rep-
tilian times when our jaws were built in five pieces to
permit of wide distention in the act of swallowing our
prey alive. All over the surface of the body are to be
found innumerable little sebaceous glands originally
intended to lubricate hairs, which have now atrophied
and disappeared. These useless scraps, under various
forms of irritation, both external and internal, become
inflamed and give rise to pimples, acne, or "a bad
complexion."

And so the list might be drawn out to most impres-
sive length. But this length would be no indication of
its real importance, inasmuch as the vast majority of
entries upon it would come under the head of patho-
logical curiosities, or conditions which were chiefly
interesting on account of their rareness and unusual
character. With the exception of the appendix, the
gall-bladder, and hernia, these vestigial conditions
may be practically disregarded as factors in the death-
rate.

In the main, when the fullest possible study and
recognition have been made of all the traces of experi-
mentation and even of ancient failure that are to be
found in this Twentieth Century body-machine of
ours, the resulting impression is one of enormously
increased respect for and confidence in the machine
and its capabilities. While they are of great interest
as indicating what the past history and experiences of
the engine have been, and of highest value as enabling
us to interpret and even anticipate certain weak spots
in its construction and joints in its armor, their most

OUR LEGACY OF HEALTH 39

striking influence is in the direction of emphasizing
the enormous elasticity and resourcefulness of the
creature.

Not only has it met and survived all these difficulties,
but it is continuing the selfsame processes to-day. So
far as we are able to judge, it is as young and as adapt-
able as it ever was, and just as ready to " with a frolic
welcome greet the thunder and the sunshine" as it ever
was in the dawn of history.

These ancestral and experimental flaws, even when
unrecognized and unguarded against, have probably
not at any time been responsible for more than one or
two per cent of the body's breakdowns ; while, on the
other hand, every process with which it fights disease,
every trick of strategy which it uses against invading
organisms, every step in the process of repair after
wounds or injury, is a trick which it has learned in its
million-year battle with its surroundings.

Take such a simple thing as the mere apparently
blind habit possessed by the blood of coagulating as
soon as it comes in contact with the edges of a cut or
torn blood-vessel, and think what an enormous safe-
guard this has been and is against the possibility of
death by hemorrhage. So well is it developed and so
rapidly does it act that it is practically impossible to
bleed some animals to death by cutting across any
vessel smaller than one of the great aortic trunks.
The rapidity and toughness of the clotting, combined
with the other ancestral tricks of lowering the blood
pressure and weakening down the heart, are so im-
mensely effective that a slash across the great artery of

40 PREVENTABLE DISEASES

the thigh in the groin of a dog will be closed completely
before he can bleed to death. So delicate and so pur-
poseful is this adjustment that the blood will continue
as fluid as milk for ten, twenty, forty, eighty years —
as long as it remains in contact with healthy blood-
vessels. But the instant it is brought in contact with a
broken or wounded piece of a vessel-wall, that instant
it will begin to clot. So inevitable is this result that it
gives rise to some of the sudden forms of death by
bloodclot in the brain or lung (apoplexy, "stroke"),
the clot having formed upon the roughened inner sur-
face of the heart or of one of the blood-vessels and then
floated into the brain or lung.

Then take that matchless and ingenious process of
the healing of wounds, whose wondrousness increases
with every step that we take into the deeper details of
its study. First, the quick outpouring and clotting of
the blood after enough has escaped to wash most poi-
sonous or offending substances out of the wound. This
living, surgical cement, elastic, self-moulding, sooth-
ing, not only plugs the cut or torn mouths of the
blood-vessels, but fills the gap of the wound level with
the surface. Here, by contact with the air and in com-
bination with the hairs of the animal it forms a tough,
firm, protective coating or scab, completely shutting out
cold, heat, irritants, or infectious germs.

Into the wedge-shaped, elastic clot which now fills
the wound from bottom to top like jelly in a mould,
the leucocytes or white blood-cells promptly migrate
and convert it into a mesh of living cells. They are
merely the cavalry and skirmishers of the repair

OUR LEGACY OF HEALTH 41

brigade and are quickly followed by the heavy infantry
of the line in the shape of cells born of the injured tis-
sues on either side of the wound. These join hands
across the gap, the engineer corps and the commissariat
department move up promptly to their support in the
form of little vein-construction switches, which bud
out from the wounded blood-vessels. The clot is
transformed into what we term granulation tissue and
begins to organize. A few days later this granulation
tissue begins to contract and pull the lips of the wound
together. If the gap has not been too wide the wound
will be completely closed, its lips and deeper parts
drawn together in nearly perfect line, separated only by
a thin scar on the surface with a vertical keel of scar
tissue descending from it. If the lips cannot be drawn
together and there be no surgical skill at hand to assist
them with stitches or bandages, then the gap will be filled
up by the fibrous transformation of this granulation
tissue and a thick, heavy scar result. Meanwhile, the
skin-cells of the surface have not been idle, but are bud-
ding out on either side of the healing wound, pushing
a little line of colonists forward across the raw surface.
In longer or shorter time, according to the width of the
gap, these two lines meet, and the site of our wound
or the scar that it has left is perfectly coated over with
a layer of healthy skin. This drama has occurred so
many score of times in every one of us that custom has
blinded our eyes to its ingenious perfection, but it took
a million years to bring it to its present finish.

It may be a healthy corrective to our overweening
conceit to remind ourselves that, remarkable and valu-

42 PREVENTABLE DISEASES

able as it is, it is a mere infant in arms compared to the
superb powers of replacement and repair possessed by
our more remote ancestors. Most invertebrates and
many of the lowest two classes of backboned animals,
the fishes and the amphibians, cannot merely stop up a
rent, but renew an entire limb, fin, — yes, even eye or
head. Cut an earthworm in two and the rear half will
grow a new head and the front half a new tail. It may
even be cut in four or five segments, each of which will
proceed to form a head at one end and a tail at the other.
The lobster can regrow a complete gill and any number
of claws or an eye. A salamander will reproduce a foot
and part of a limb. Take out the crystalline lens in the
eye of a salamander and the edge of the iris, or colored
part of the eye, will grow another lens. Take out both
the lens and the iris and the choroid coat of the eye will
reproduce both.

We are in the A, B, C class in powers of repair by
comparison with the angleworm, the lobster, or the sala-
mander. Yet we are not without gruesome echoes of
this lost power of regeneration in that our whole brood
of tumors, including the deadly cancer and sarcoma, are
due to a strange resumption, on the part of some little
knot of our body-cells, of the power of reproducing
themselves or the organ in which they are situated,
without any regard to the welfare of the rest of the body.
Cancer is, in one sense, a throwing off of the allegiance
to the body-state and a resumption of amphibian powers
of independent growth on the part of certain groups
of our body-cells — literally, a "rebellion of the cells."

These are but a handful of scores of instances that

OUR LEGACY OF HEALTH 43

could be adduced, showing that the majority of the
processes upon which we rely in combating disease and
preserving life are the result of the hereditary experi-
ences of our cells. Intelligent physicians are receding
completely from that curiously warped and jaundiced
view which led us to regard heredity chiefly as a factor
in the production of disease. It was, perhaps, natural
enough, since it was inevitably only its injurious, or, so
to speak, malicious, effects which were brought to our
attention to be corrected. But, just as in the growth of
our ethnic religions it is Evil that is worshiped first as
strongest and most aggressive, and the recognition of
the greater power of good comes only at a later stage,
so it has been in pathology.

Not only do we regard heredity as a comparatively
small and steadily receding factor in the production of
disease, but we fully and frankly recognize it as the
strongest and most important single force in its pre-
vention. All our processes of repair, all the reactions
of the body against the attack of accident or of disease,
are hereditary endowments, worked out with infinite
pains and labor through tens of thousands of genera-
tions. The utmost that we can do with our drugs and
remedies is to appeal to and rouse into action the great
healing power of nature, the classic " Vis medicatrix
Nature?" an incarnation of our past experiences
handed down by heredity. Enormously valuable and
important as are the services to human welfare, health,
and happiness which can be rendered by the destruc-
tion of the living external causes of disease and the
prevention of contagion, our most permanent and sub-

44 PREVENTABLE DISEASES

stantial victories are won by appealing to and increas-
ing this long-descended and hard-won power of indi-
vidual resistance.

" But," says some one at once, " I thought there were
a large number of hereditary diseases." Fifty years ago
there were a score of such, twenty years ago the score
had sunk to five or six. Now there is scarcely one left.
There is no known disease which is directly inherited as
such. There is scarcely even a disease in which we now
regard heredity as playing a dominant or controlling
part. Among the few diseases in which there is serious
dispute as to this are tuberculosis, insanity, epilepsy,
and cancer.

Then there are diseases which for a long time puzzled
us as to the possibility of their inheritance, but which
have now resolved themselves clearly into instances of
the fact that a mother who happens to contract an acute
infectious disease of any sort may communicate that
disease to the unborn child. If this occurs at an early
stage of development the child will naturally be
promptly killed. In fact, this is the almost invariable
result in smallpox and yellow fever. If, on the other
hand, development be further advanced or the infection
be of a milder character, like scarlet fever or syphilis,
the child may be born suffering with the disease or with
the vims in its blood, which will cause the disease to
develop within a few days after birth. This, however,
is clearly not inheritance at all, but direct infection.
We no longer use the term hereditary syphilis but have
substituted for it the word congenital, which simply
means that a child is born with the disease.

OUR LEGACY OF HEALTH 45

There is no such thing as this disease extending
"unto the third and fourth generation," like the wrath
of Jehovah. One fact must, of course, be remembered,
which has probably proved a source of confusion in the
popular mind, and that is its extraordinary "long-
windedness. " It takes not merely two or three weeks
or months to develop its complete drama, but any-
where from three to thirty years, so that it is possible
for a child to be born with the taint in its blood and
yet not exhibit to the non-expert eye any sign of the
disease until its eighth, twelfth, or even fifteenth
year.

The case of tuberculosis is almost equally clear-cut.
In all the thousands of post-mortem examinations
which have been held upon newborn children and upon
mothers dying in or shortly after childbirth, the number
of instances of the actual transference of the bacilli of
tuberculosis from mother to child could be counted
upon the fingers of two hands. It is one of the rarest of
pathologic curiosities and, for practical purposes, may
be entirely disregarded. When tuberculosis appears in
several members of a family, in eight cases out of ten
it is due to direct infection from parents or older chil-
dren. This is strikingly brought out in the admirable
work done by the Associated Dispensaries for Tuber-
culosis of the Charity Organization Society of New
York.

One of the first steps in advance which they took was
to establish in connection with every clinic for tubercu-
losis an attendant nurse, whose duty it was to visit the
patients at their homes and advise and instruct them as

46 PREVENTABLE DISEASES

to improvements in their methods of living, ventilation,
food, and the prevention of infection.

It was not long before these intelligent women began
to bring back reports of other cases in the same family.
Now the procedure is regularly adopted, whenever a
case presents itself, of rounding up the remainder of the
family group for examination, with the astounding re-
sult that where a mother or father is tuberculous, from
twenty to sixty per cent of the children will be found to
be suffering from some form of the infection. Instances
of three infected children out of five living in the same
room with a tuberculous mother are actually on
record.

No one can practice long in any of our great climatic
health resorts for tuberculosis, like Colorado or the
Pacific Slope, without coming across scores of painful
and distressing instances of children of tuberculous
parents dying suddenly in convulsions from tuberculous
meningitis, or by a wasting diarrhoea from tuberculo-
sis of the bowels, or from a violent attack of distention.
of the bowels due to tuberculous peritonitis. The favor-
ite breeding-place of the tubercle bacillus is unfortu-
nately in the home.

On the other hand, while the vast majority of cases of
so-called hereditary tuberculosis are due to direct infec-
tion, and may be prevented by proper disposal of the
sputum and other methods for avoiding contagion, there
is probably a hereditary element in the spread of tuber-
culosis to this degree : that, inasmuch as all of us have
been exposed to the attack and invasion of the tubercle
bacillus, not merely scores, but hundreds of times, and

OUR LEGACY OF HEALTH 47

have been able to resist or throw off that attack without
apparent injury, the development of an invasion of the
tubercle bacillus sufficiently extensive to endanger life
is, in nine cases out of ten, in itself a proof of lowered
resisting power on the part of the patient. This may be,
and often is, only temporary, due to overwork, under-
feeding, overconfinement, or that form of gradual suffo-
cation which we politely term inadequate ventilation.

In a certain percentage of cases, however, it is due to
a chronic lack of vigor and vitality ; a lowering of the
whole systemic tone, which may have existed from
birth. In that case it is hardly to be expected that
such an individual, becoming a parent, will be able
to transmit to his or her offspring more vigor than he
originally possessed. It is therefore probable that the
children of a considerable percentage of tuberculous
parents would not possess the same degree of resisting
power against tuberculosis, or any other infection, as
the average individual.

It is doubtful whether this factor of inherited lowered
resistance plays any very important part in the propaga-
tion of tuberculosis, partly because it is comparatively
seldom that consumptive marries consumptive, and
such tendencies to lowered vigor and vitality as may be
transmitted by one parent will be neutralized by the
other ; partly also because, by the superb and beneficent
logic of nature, the pedigree of any disease is of the
most mushroom and insignificant length, while the
pedigree of health stretches back to the very dawn of
time. In the struggle for dominance which takes place
between the germ cells of the father and those of the

48 PREVENTABLE DISEASES

mother, the chances are at least ten to one in favor of
the old ancestral traits of vigor, of resisting power, and
of survival. How deeply this idea is implanted in the
convictions of the scientific world, the bitterly and
widely debated biologic question whether acquired
characters or peculiarities can under any circumstances
be inherited clearly shows. Victory for the present
rests with those who deny the possibility of such in-
heritance, and disease is emphatically an acquired
character.

Truth here, as everywhere, probably lies between the
extremes, and both biologists and the students of disease
have arrived at practically the same working compro-
mise, namely, that while no gross defect, such as a
mutilation, nor definite disease factor, such as a germ,
nor even a cancer, can possibly be inherited, yet, inas-
much as the two cells, which by their development
form the new individual, are nourished by the blood of
the maternal body, influences which affect the nutri-
tiousness or healthfulness of that blood may unfavor-
ably influence the development of the offspring.

Disease cannot be inherited any more than a mutilat-
ing defect, but the results of both, in so far as they
affect the nutrition of the offspring in the process of
formation, may be transmitted, though to a very much
smaller extent than we formerly believed. In the case
of tuberculosis, if the mother, during the months that
she is building up the body and framework of a child,
is in a state of reduced or lowered nutrition on account
of consumption or any other disease, or has her tissues
saturated with the toxins of this disease, it is hardly to

OUR LEGACY OF HEALTH 49

be expected that the development of the child will pro-
ceed with the same perfection as it would under per-
fectly normal maternal surroundings.

However, even this influence is comparatively small ;
for one of the most marvelous things in nature is the
perfection of the barrier which she has erected between
the child before birth and any injurious conditions
which may occur in the body of the mother. Here pre-
ference, so to speak, is given to the coming life, and
whenever there is a contest for an adequate supply of
nutrition, as, for instance, in cases of underfeeding or of
famine, it is the mother who will suffer in her nutrition
rather than the child. *The unborn child, biologically
considered, feeds upon the best she has to offer, reject-
ing all that is inferior, doing nothing and giving nothing
in return.

How perfectly the coming generation is protected
under the most unfavorable circumstances we have
been given a striking object-lesson in one family of
the lower animals. In the effective crusade against
tuberculosis in dairy cattle waged by the sanitary
authorities in Denmark, it was early discovered that
the greatest practical obstacle to the extermination of
tuberculosis in cattle was the enormous financial
sacrifice involved in killing all animals infected. The
disease was at that time particularly rife among the
high-bred Jersey, Holstein, and other milking breeds.
It was determined as a working compromise to test the
truth of the modern belief that tuberculosis was trans-
mitted only by direct infection, by permitting the more
valuable cows to be saved alive for breeding purposes.

50 PREVENTABLE DISEASES

They were isolated from the rest of the herd and given
the best of care and feeding. The moment that their
calves were born they were removed from them alto-
gether and brought up on the milk of perfectly healthy
cows. The milk of the infected cows was either
destroyed or sterilized and used for feeding pigs.

The results were brilliantly successful. Scarcely one
of the calves thus isolated developed tuberculosis in
spite of their highly infected ancestry. And not only
were they not inferior in vigor and perfection of type
to the remainder of their breed, but some of them have
since become prize-winners. The additional care and
more abundant feeding that they received more than
compensated for any problematic defect in their he-
redity.

As to the heredity of cancer, all that can be said is that
the burden of proof rests upon those who assert it. It is
really curious how widespread the belief is that cancer
" runs in families," and how exceedingly slender is the
basis of evidence for such a belief. There are so many
things that we do not know about cancer that any posi-
tive statement of any kind would be unbecoming. It
would be absurd to declare that a disease, of which the
cause is still unknown, either is or is not inherited. And
this is our position in regard to cancer. An overwhelm-
ing majority of the evidence so far indicates that it is not
a parasite ; if it were, of course, we could say positively
that it is not inherited. Although we are getting a dis-
couraging degree of familiarity with the process and
clearly recognize that it consists chiefly in the sudden
revolt or rebellion of some group of cells, a tendency

OUR LEGACY OF HEALTH 51

which quite conceivably might be transmitted to future
generations, yet it is highly improbable, on both biologi-
cal and pathological grounds, that such is the case. If
this rebellious tendency were transmitted we should at
least have the right to expect that 'it would appear in the
cells of the same organ or region of the body. It is a
singular fact that in all the hundreds of cases in which
cancer has appeared in the child of a cancerous parent
it has almost invariably appeared in some different
organ from that affected in the parent.

For instance, cancer of the lip in the father may be
followed by cancer of the liver in the son or daughter,
while cancer of the breast in the mother will be fol-
lowed by cancer of the lip in a son. Further than this,
the percentage of instances in which cancer appears in
more than one member of a family is decidedly small,
considering the frequency of the disease.

I took occasion to look into the matter carefully from
a statistical point of view some ten or twelve years ago,
and out of a collection of some fifty thousand cases of
cancer less than six per cent were found to give any his-
tory of cancer in the family. And this, of course, simply
means that some one of the relatives of the patient had
at one time developed the disease.

In fact, the consensus of intelligent expert opinion
upon the subject of heredity of cancer is, that though it
may occur, we have comparatively little proof of the
fact; that the percentage of cases in which there is
cancer in the family is but little larger than might be
expected on the doctrine of probabilities from- the aver-
age distribution. Though possibly the offspring of a

52 PREVENTABLE DISEASES

cancerous individual may display a slightly greater ten-
dency toward the development of that strange, curious
process of "autonomy" than the offspring of the aver«
age individual, this tendency is so small and occurs so
infrequently as to be a factor of small practical import-
ance in the propagation and spread of the disease.

In insanity and epilepsy we have probably the last
refuge and almost only valid instance of the old belief
in the remorseless heredity of disease. But even here
the part played by heredity is probably only a fraction
of that which it is popularly, and even professionally,
believed to play. It is, of course, obvious that diseases
which tend quickly to destroy the life of the patient,
especially those which kill or seriously cripple him
before he has reached the age of reproduction, or pre-
vent his long surviving that epoch, will not, for me-
chanical reasons, become hereditary. The Black Death,
or the cholera, for instance, could not " run in a family."
Supposing that children were born with a special sus-
ceptibility to this disease, there would obviously soon
be no family left.

The same is true in a lesser degree of milder or more
chronic diseases. The family which was hereditarily
predisposed to scarlet fever, measles, smallpox, or tuber-
culosis would not last long, and in fact the whole pro-
gress of civilization has been a continuous process of
the weeding out of those who were most susceptible and
the survival of those who were least so.

But when we come to deal with certain conditions,
fortunately rare, such as functional disturbances of the
nervous system, which neither seriously unfit their pos-

OUR LEGACY OF HEALTH 53

sessor for the struggle of life nor prevent him from
reproducing his kind, then it becomes possible that a
tendency to such disease may be transmitted through
several successive generations.

Such is the case with insanity, with epilepsy, with
hemophilia, or " bleeders," and with certain rare and
curious disturbances of the nervous system, such as the
hereditary ataxias and "tics" of various sorts. How-
ever, even here the only conditions on which these
diseases can continue to run in a family for more than
one or two generations is either that they shall be mild
in form or that only a comparatively small percentage
of the total family shall be affected by them. If, for
instance, two-thirds, one-half, or even a third of the
descendants of a mentally unsound individual were to
become insane, it would only need a few generations for
that family to be crushed to the wall.

While the descendants of insane persons are distinctly
more liable to become insane than the rest of the com-
munity, yet, on account of their fewness, this tendency
probably does not account for more than a small frac-
tion of the total insanity. We should, by all means,
prevent the marriage of the insane and discourage that
of their children, and the development of any well-
defined form of insanity should act at once, ipso facto,
as a ground and cause of divorce.

But the consoling fact remains that even of such
children, providing, of course, as usually happens, that
the other parent — husband or wife — is sound and
sane, not more than ten or fifteen per cent would
probably become insane. In other words, insanity is

54 PREVENTABLE DISEASES

acquired and the result of individual stress and strain
at least five times as frequently as it is inherited. We
have absolutely no rational or statistical basis for gloomy
predictions that, at present 'rates, within a couple of
centuries more, we shall all be shut up in asylums with
nobody left to support us and pay the taxes. The
apparent increase of insanity of recent decades is prob-
ably only "on paper," due to better registration.

To put it very roughly, probably ninety-eight per
cent of us are so born, thanks to heredity, that the pos-
sibility of our becoming insane, even under the severest
stress, is almost infinitesimal. Of the two per cent born
with this taint, this possible tendency to mental unbal-
ance, only about one-tenth now become completely
insane,1 and this percentage might be greatly diminished
by general sanitary improvements. Our alienists now
claim that, by checking the reproduction of the obvi-
ously unstable, and careful hygienic treatment and
training of the predisposed two per cent, insanity is
almost as preventable as tuberculosis.

In fine, from all the broad field of pathology, the
mists of tradition which have dimmed the fair name
and reputation of heredity are slowly but surely lifting,
until we now behold it, not as our worst enemy, but as
our best friend in the prevention of disease and the
upbuilding of the race.

1 The proportion of registered insane in civilized countries to-day
ranges from two to three per 1000 of the population.

CHAPTER III

THE PHYSIOGNOMY OF DISEASE I WHAT A DOCTOR
CAN TELL FROM APPEARANCES

IT is our pride that medicine, from an art, and a
pretty black one at that, originally, is becoming a
science. And the most powerful factor in this devel-
opment, its indispensable basis, in fact, has been the
invention of instruments of precision — the micro-
scope, the fever thermometer, the stethoscope, the oph-
thalmoscope, the test-tube, the culture medium, the
triumphs of the bacteriologist and of the chemist.
Any man who makes a final diagnosis in a serious case
without resorting to some or all of these means is re-
garded — and justly — as careless and derelict in his
duty to his patient.

At the same time, priceless and indispensable as are
these laboratory methods of investigation, they should
not be allowed to make us too scornful and neglectful
of the evidence gained by the direct use of ourfive senses.
We should still avail ourselves of every particle of in-
formation that can be gained by the trained eye, the
educated ear, the expert touch, — the tactus eruditus
of the medical classics, — and even the sense of smell.
There is, in fact, a general complaint among the older
members of the profession that the rising generation
is being trained to neglect and even despise the direct
evidence of the senses, and to accept no fact as a fact

56 PREVENTABLE DISEASES

unless it has been seen through the microscope or
demonstrated by a reaction in the test-tube. As one of
our keenest observers and most philosophic thinkers
expressed it a few months ago : —

"I fear that certain physicians on their rounds are
most careful to take with them their stethoscope, their
thermometer, their hemoglobin papers, their sphygmo-
manometer, but leave their eyes and their brains at
home."

And it is certain that the art of sight diagnosis,
which seems like half magic, possessed in such a won-
derful degree by the older physicians of the passing
and past generations, has been almost lost by the
new.

A healthful reaction has, however, set in ; and while
we certainly do not love the Caesar of laboratory
methods and accuracy the less, we are beginning to
have a juster affection for the Rome of the rich harvest
that may be gained from the careful, painstaking, de-
tective-like exercise of our eye, ear, and hand.

As a matter of fact, the conflict between the two
methods is only apparent. Not only is each in its pro-
per sphere indispensable, but they are enormously
helpful one to the other. Instead of our being able to
tell less by the careful, direct eye-and-hand examina-
tion of our patients than the doctor of a century ago,
we can tell three to five times as much. Signs that he
could interpret only by the slow and painful method
of two-thirds of a lifetime of plodding experience, or
by occasional flashes of half-inspired insight, we are
now able to interpret absolutely upon a physiological

THE PHYSIOGNOMY OF DISEASE 57

— yes, a chemical — basis from the revelations of the
microscope, the test-tube, and the culture medium.
His only way of determining the meaning of a particu-
lar tint of the complexion, or line about the mouth, or
eruption on the skin, was by slowly and laboriously
accumulating a long series of similar cases in which
that particular symptom was found always to occur,
and deducing its meaning. Now, we simply take a drop
of our patient's blood, a scraping from his throat, a
portion of some one of his secretions, a little slice of
a tumor or growth, submit them to direct examina-
tion in the laboratory, and get a prompt and decisive
answer.

The observant physician begins to gather informa-
tion about a patient from the moment he enters the
sick-room or the patient steps into his consulting-
room; and the value of the information obtained in
the first thirty seconds, before a word has been spoken,
is sometimes astonishingly great. While no intelligent
man would dream of depending upon this first coup
d'ceil, "stroke of the eye" as the French so graphically
call it, for his final diagnosis, or accept its findings until
he had submitted them to the most ruthless cross-ex-
amination with the stethoscope and in the laboratory,
yet it will sometimes give him a clew of almost priceless
value. It is positively uncanny to see the swift, intuitive
manner in which an old, experienced, and thoughtful
physician will grasp the probable nature of a case in
one keen look at a patient. Often he can hardly ex-
plain to you himself how he does it, what are the data
that determine it ; yet not infrequently, three times out

58 PREVENTABLE DISEASES

of five, your most elaborate and painstaking study of
the case with all the modern methods will bring you to
the same conclusion as that sensed within forty-five
seconds by this keen-eyed old sleuth-hound of the
fever trails. Time and again, in my interne days, have
I gone the rounds of the wards or the out-patient de-
partments with some kindly-faced, keen-eyed old
Sherlock Holmes of the profession, and seen him point
to a new case across the ward with the question : " When
did that pneumonia come in?" or pick out a pain-
drawn, ashy mask in the waiting line, with an abrupt,
" Bring me that case of cancer of the stomach. He's
in pain. I '11 take him first."

And, in later years, I have had colleagues with whom
it was positively painful to walk down a crowded street,
from the gruesome habit that they had of picking out,
and condemning to lingering deaths, the cases of can-
cer, of Bright's disease, or of locomotor ataxia, that we
happened to meet. Of course, they would be the first
to admit that this was only what they would term a
"long shot," a guess; but it was a guess based upon
significant changes in the patient's countenance or gait,
which their trained eye picked out at once, and it was
surprising how often this snapshot diagnosis turned
out to be correct.

The first thing that a medical student has to learn
is that appearances are not deceptive — except to fools.
Every line of the human figure, every proportion of a
limb, every detail of size, shape, or relation in an organ,
means something. Not a line upon any bone in the
skeleton which was not made by the hand-grip or thumb-

THE PHYSIOGNOMY OF DISEASE 59

print of some muscle, tendon, or ligament; no bump
or knuckle which is not a lever or hand-hold for the
grip of some muscle; not a line or a curve or an
opening in that Chinese puzzle, the skull, which
was not made to protect the brain, to accommodate
an eye, to transmit a blood- vessel, or to allow the escape
of a nerve. Every minutest detail of structure means
something to the man who will take the pains to puz-
zle it out. And if this is true of the foundation struc-
ture of the body, is it to be expected that the law ceases
to run upon the surface ?

Not a line, not a tint, not a hollow of that living pic-
ture, the face, but means something, if we will take the
time and labor to interpret it. Even coming events cast
their shadows before upon that most exquisitely re-
sponsive surface — half mirror, half sensitive plate — •
the human countenance. The place where the moving
finger of disease writes its clearest and most unmis-
takable message is the one to which we must naturally
turn, the face ; not merely for the infantile tenth part
of a reason which we often hear alleged, that it is the
only part of the body, except the hand, which is ha-
bitually exposed, and hence open to observation, but
because here are grouped the indicators and registers
of almost every important organ and system in the body.

What, of course, originally made the face the face,
and, for the matter of that, the head the head, was the
intake opening of the food-canal, the mouth. Around
this necessarily grouped themselves the outlook de-
partments, the special senses, the nose, the eyes, and
ears; while later, by an exceedingly clumsy device

60 PREVENTABLE DISEASES

of nature, part of the mouth was split off for the intake
of a new ventilating system. So that when we glance
at the face we are looking first at the automatically
controlled intake openings of the two most important
systems in the body, the alimentary and the respiratory,
whose muscles contract and relax, ripple in comfort or
knot in agony, in response to every important change
that takes place throughout the entire extent of both.

Second, at the apertures of the two most important
members of the outlook corps, the senses of sight and
of smell. These are not only sharply alert to every ex-
ternal indication of danger, but by a curious reversal,
which we will consider more carefully later, reflect
signals of distress or discomfort from within. Last,
but not least, the translucent tissues, the semi-trans-
parent skin, barely veiling the pulsating mesh of my-
riad blood-vessels, is a superb color index, painting in
vivid tints — "yellow, and ashy pale, and hectic red"
— the living, ever changing, moving picture of the
vigor of the life-centre, the blood-pump, and the rich-
ness of its crimson stream. Small wonder that the
shrewd advice of a veteran physician to the medical
student should be : " The first step in the examination
is to look at your patient ; the second is to look again,
and the third to take another look at him ; and keep
on looking all through the examination."

It is no uncommon thing for an expert diagnostician
deliberately to lead the patient into conversation upon
some utterly irrelevant subjects, like the weather, the
crops, or the incidents of his journey to the city, simply
for the purpose of taking his mind off himself, putting

THE PHYSIOGNOMY OF DISEASE 61

him at his ease, and meanwhile quietly deciphering
the unmistakable cuneiform inscription, often twice
palimpsest, written by the finger of disease upon his
face. It takes time and infinite pains. In no other
realm does genius come nearer to Buffon's famous
description, "the capacity for taking pains," but it is
well worth the while. And with all our boasted and
really marvelous progress in precise knowledge of dis-
ease, accomplished through the microscope in the
laboratory, it remains a fact of experience that so
careful and so trustworthy is this face-picture when
analyzed, that our best and most depended upon im-
pressions as to the actual condition of patients, are
still obtained from this source. Many and many a time
have I heard the expression from a grizzled consultant
in a desperate case, "Well, the last blood-count was
better," or, "The fever is lower," or, "There is less
albumen, — but I don't like the look of him a bit";
and within twenty-four hours you might be called in
haste to find your patient down with a hemorrhage,
or in a fatal chill, or sinking into the last coma.

It would really be difficult to say just what that care-
ful and loving student of the genus humanum known
as a doctor looks at first in the face of a patient. In-
deed, he could probably hardly tell you himself, and
after he has spent fifteen or twenty years at it, it has
become such a second nature, such a matter of instinct
with him, that he will often put together all the signs
at once, note their relations, and come to a conclusion
almost in the " stroke of an eye," as if by instinct, just
as a weather-wise old salt will tell you by a single glance

62 PREVENTABLE DISEASES

at the sky when and from what quarter a storm is
coming.

I shall never forget the remark of my greatest and
most revered teacher, when he called me into his con-
sultation-room to show me a case of typical locomotor
ataxia, gave me a brief but significant history, put the
patient through his paces, and asked for a diagnosis.
I hesitated, blundered through a number of further un-
necessary questions, and finally stumbled upon it.
After the patient had left the room, I, feeling rather
proud of myself, expected his commendation, but I
did n't get it. "My boy," he said, "you are not up to
the mark yet. You should be able to recognize a dis-
ease like that just as you know the face of an acquaint-
ance on the street." A positive and full-blown diagno-
sis of this sort can, of course, only be made in two or
three cases out of ten. But the method is both logical
and scientific, and will give information of priceless
value in ninety-nine cases out of a hundred.

Probably the first, if not the most important, char-
acter that catches the physician's eye when it first falls
upon a patient is his expression. This, of course, is a
complex of a number of different markings, but chiefly
determined by certain lines and alterations of position
of the skin of the face, which give to it, as we frequently
hear it expressed, an air of cheerfulness or depression,
comfort or discomfort, hope or despair. These lines,
whether temporary or permanent, are made by the
contractions of certain muscles passing from one part
of the skin to another or from the underlying bones to
the skin. These are known in our anatomical text-

THE PHYSIOGNOMY OF DISEASE 63

books by the natural but absurd name of "muscles
of expression."

Their play, it is true, does make up about two-thirds
of the wonderful shifting of relations, which makes the
human countenance the most expressive thing in the
world ; but their original business is something totally
different. Primarily considered, they are solely for the
purpose of opening or closing, contracting or expand-
ing, the different orifices which, as we have seen, ap-
pear upon the surface of the face. This naturally throws
them into three great groups: those about and con-
trolling the orifice of the alimentary canal, the mouth ;
those surrounding th£ joint openings of the air-tube
and organ of smell, and those surrounding the eyes.

As there are some twenty-four pairs of these in an
area only slightly greater than that of the outspread
hand, and as they are capable of acting with every
imaginable grade of vigor and in every possible com-
bination, it can readily be seen what an infinite and
complicated series of expressions — or, in other words,
indications of the state of affairs within those differ-
ent orifices — they are capable of. Only the barest
and rudest outlines of their meaning and principles
of interpretation can be attempted. To put it very
roughly, the main underlying principle of interpretation
is that we make our first instinctive judgment of the
site of the disease from noting which of the" three great
orifices is distorted furthest from its normal condition.
Then by constructing a parallel upon the similarity
or the difference of the lines about the other two open-
ings, we get what a surveyor would call our " lines of

64 PREVENTABLE DISEASES

triangulation," and by following these to their con-
verging point can often arrive at a fairly accurate
localization.

The greatest difficulty in the method, though at
times our greatest help, is the extraordinary and inti-
mate sympathy which exists between all three of these
groups. If pain, no matter where located, once becomes
intense enough, its manifestations will travel over the
face-dial, overflowing the organ or system in which it
occurs, and eyes, nostrils, and mouth will alike reveal
its presence. Here, of course, is where our second great
process, so well known in all clew-following, elimina-
tion, comes in.

A patient comes in with pain-lines written all over
his face. To put it very roughly — has he cancer of the
stomach? Pneumonia? Brain tumor? If there be
no play of the muscles distending and contracting the
nostrils with each expiration, no increased rapidity of
breathing, no gasp when a full breath is drawn, and
no deep red fever blush on the cheeks, we mentally
eliminate pneumonia. The absence of these nasal
signs throws us back toward cancer or some other pain-
ful affection of the alimentary canal. If the pain-lines
about the mouth are of recent formation, and have not
graved themselves into the furrows of the forehead
above and between the eyebrows ; if the color, instead
of ashy, be clear and red, we throw out cancer and think
of colic, ulcer, hyperacidity, or some milder form of
alimentary disease.

If, on the other hand, the pain-lines are heaviest
about the brows, the eyes, and the forehead, with only

THE PHYSIOGNOMY OF DISEASE 65

a sympathetic droop or twist of the corners of the
mouth, if the nostrils are not at all distorted or too
movable, if there is no fever flush and little wasting,
and on turning to the eyes we find a difference between
the pupils, or a wide distention or pin-point-like con-
traction of both or a slight squint, the picture of brain
tumor would rise in the mind. Once started upon any
one of these clews, then a hundred other data would
be quickly looked for and asked after, and ultimately,
assisted by a thorough and exhaustive examination
with the instruments of precision and the tests in the
laboratory, a conclusion is arrived at. This, of course,
is but the roughest and crudest outline suggestive of
the method of procedure.

Probably not more than once in three times will the
first clew that we start on prove to be the right one;
but the moment that we find this barred, we take up
the next most probable, and in this manner hit upon
the true scent.

As to the cause and rationale of these pain-lines, only
the barest outlines can be given. Take the mouth for
an example. When all is going well in the alimentary
canal, without pain, without hunger, and both absorp-
tion of food and elimination of waste are proceeding
normally, the tissues about the mouth, like those of
the rest of the body, are apt to be plump and full ; the
muscles which open the aperture, having fulfilled their
duty and received their regular wages, are quietly at
rest ; those that close the opening, having neither anti-
cipation of an early call for the admission of necessary
nutriment, nor an instinctive desire to shut out any-

66 PREVENTABLE DISEASES

thing that may be indigestible or undesirable, are now
in their normal condition of peaceful, moderate con-
traction; the face has a comfortable, well-fed, whole-
some look. On the other hand, let the digestive juices
fail to do their duty properly, or the swarms of bacteria
pets which we keep in our food-canals get beyond con-
trol ; or if for any other reason the tissues be kept from
getting their proper supply of nourishment from the
food-canal, the state of affairs is quickly revealed in the
mouth mirror. Those muscles which open the mouth,
instead of resting peacefully in the consciousness of
duty well done, are in a state of perpetual fidget, twitch-
ing, pulling, wondering whether they ought not to open
the portal for the entrance of new supplies of material,
since the tissues are crying for food.

As the strongest of these are those which pull the
corners of the mouth outward and downward, the re-
sultant expression is one of depression, with downward-
curving angles to the mouth. The eyes, and even the
nostrils, sympathetically follow suit, and we have that
countenance which, by the cartoonist's well-known
trick, can be produced by the alteration of one pair of
lines, those at the angles of the mouth, turning a smiling
countenance into a weeping one. .On the other hand,
if all these processes of nutrition and absorption are
proceeding as they should, they are accompanied by
mild sensations of comfort which, although they no
longer reach our consciousness, reveal themselves in
the mouth-opening muscles, and they gently contract
upward and outward, in pleasurable anticipation of
the next intake, and we get the grin or the smile.

THE PHYSIOGNOMY OF DISEASE 67

If, on the other hand, these digestive disturbances be
accompanied by pain, then another shading appears
on our magic mirror, and that is a curious contraction
of the mouth, with distortion of the lines surrounding
it, so violent in some cases as positively to whiten the
lips or produce lines of paleness along the course of the
muscles. This is the set or twisted mouth of agony,
and is due to a curious transference and reflex on this
order: that inasmuch as the last food which entered
the alimentary canal -seems to have caused this dis-
turbance and pain, no more will be allowed to enter
it at present under any conditions. And as our alimen-
tary instincts are the most fundamental of all, by a due
process of transference, mental agony calls into action
this same set of muscles, to shut out any possible addi-
tion to the agony already present.

The lines of determination, similarly, about the
mouth, are those of the individual who has the courage
to say "No" to the tempting morsel when he does n't
need it ; and the lines of weakness and irresolution are
those of the nature which cannot resist either gastro-
nomic or other temptation. Similarly, the well-known
lines of disgust or of discontent about the corners of the
mouth are the unconscious contractions accompanying
nausea, and preparations to expel the offending morsel
whether from stomach or mouth.

If, on the other hand, our first glance shows us that
the deepest pain-lines are those about the nostrils and
upper lip, especially if the wings of the nostrils can be
seen to dilate with each breath, and breathing be faster
than normal, our clew points in the direction of some

68 PREVENTABLE DISEASES

disease of the great organs above the diaphragm — that
is, the lungs or heart.

Signs in this region might refer to either of these, for
the reason that, although a sufficient intake of air is one
of the necessary conditions of proper oxygenation, a
free and abundant circulation of the blood through the
air-cells is equally essential. In fact, that common
phenomenon known as "shortness of breath" is more
frequently due to disturbances of the heart and circula-
tion than it is to the lungs, especially in patients who
are able to be up and about. If, in addition to the dan-
ger signal of the rise and fall of the nostrils with each
breath, we have a pale, translucent skin, with a light,
hectic flush showing just below the knife-like lower
edge of the cheekbone, a widely open, shining eye, and
a clustering abundance of hair of a glossiness border-
ing on dampness, red lips slightly parted, showing the
teeth between, a painfully strong suspicion of consump-
tion would arise unbidden.

This pathetic type of face has that fatal gift which
the French clinicians, with their usual happiness of
phrase, term La beauU dudiable. The eager eyes, di-
lated nostrils, parted lips, give that weird air of exal-
tation which, when it occurs, as it occasionally does
in the dying, is interpreted as the result of glimpses
into a spirit world. When to this is added the mild
delirium of fever, when memories of happier days and
of those who have passed before rise unbidden and
babble themselves from the tongue, one can hardly
wonder at this interpretation.

The last group of lines to be noted is that about the

THE PHYSIOGNOMY OF DISEASE 69

eyes and forehead. These are less reliable than either
of the other two, for the reason that they are so sym-
pathetic as almost invariably to be present in addition,
whenever the lower dial-plates of the face are disturbed.
It is only when they appear alone that they are signifi-
cant; then they may be interpreted as one of three
things : first, and commonest, eye strain ; second, dis-
ease in some part of the nervous system or muscular
system, not connected with the organs of the chest or
abdomen; and third, mental disturbances.

This last relation, of course, makes them in many
respects the least reliable of all the face indices, be-
cause — as is household knowledge — they indicate
mental conditions and operations, as well as bodily.
"The wrinkled brow of thought," the "deep lines of
perplexity," etc., are in the vocabulary of the grammar
grades. They are, however, a valuable check upon the
other two groups. They are not apt to be present in
consumption and in other forms of serious disease,
attended by fever, on account of the curious effect
produced by the toxins of the disease,. which is often
not only stimulating, but even of an exhilarating
nature, or will produce a slight stupor or lethargy,
such as is typical of typhoid.

One of the most singular transformations in the sick-
room, especially in serious disease marked by lethargy
or stupor, is that in which the patient's countenance
will appear like a sponged-off slate, so completely have
the lines of worry and of thought been obliterated.

One distinct value of the pain-lines about the eyes
and brow is that you can often test their genuineness.

70 PREVENTABLE DISEASES

Just engage your hypochondriac or hysterical patient
in lively conversation; or, on the reverse principle,
wound his vanity, so as to produce an outburst of tem-
per, and see how the lines of undying agony will fade
away and be replaced by the curves of amusement or
by the straight-drawn brows of indignation.

As with the painter, next to line comes color. Every
one, of course, knows that a fresh, rosy color is usually
associated with health, while a pale, sallow complex-
ion suggests disease. But our color signals, while more
vivid, are much less reliable and more apt to deceive
than our line-markings.

Surprising as it may sound, careful analyses have
shown, first, that the kind of pigment present in the
human skin of every race is absolutely one and the
same. The only difference between the negro and the
white man is that the negro has two or three times as
much of it. Secondly, that every skin except that of the
albino has a certain, and usually a considerable, amount
of this pigment present in it.

" The red hue of health " is even more apt to mis-
lead us, because, being due to the abundance of blood
in the meshes of the skin, many fevers, by increasing
the rapidity of the heart-beat and dilating the vessels
in the skin, give a ruddiness of hue equal to or in ex-
cess of the normal.

However, a little careful checking up will eliminate
most of the possible mistakes and enable us to obtain
information of the greatest value from color. For in-
stance, if our patient be of Southern blood, or tanned
from the seashore, the good red blood in his arteries is

THE PHYSIOGNOMY OF DISEASE 71

pretty safe to show through at the normal blush area
on the cheeks ; or, failing that, through the translucent
epithelium of the lips and gums. If, on the other hand,
this yellow tint be due to the escape of broken-down
blood-pigments into the tissues, or a damming up of
the bile, and a similar escape of its coloring matter, as
in jaundice, then we turn to the whites of the eyes, and
if a similar, but more delicate, yellowish tint confronts
us there, we know we have to deal with a severe form
of anaemia or jaundice, according to the tint. In ex-
treme cases of the latter, the mucous membrane of the
lips and of the gums will even show a distinctly yellow-
ish hue. The frightfuf color of yellow fever, and the
yellow " death mask," which appears just before the
end of several fatal forms of blood poisoning, is due to
the tremendous breaking down of the red cells of the
blood under the attack of the fever toxins, and their
leaking out into the tissues. A similar process of a
milder and less serious extent occurs in those tempo-
rary anaemias of young girls, known for centuries past
in the vernacular as " the green sickness." And a deli-
cate lemon tint of this same origin, accompanied by a
waxy pallor, is significant of the deadly, pernicious
anaemia and the later stages of cancer.

The most significant single thing about the red flush,
supposed to be indicative of health, is its location. If
this be the normal " blush area," about the middle of
each cheek, — which is one of nature's sexual orna-
ments, placed, like a good advertisement, where it will
attract most attention and add most beauty to the
countenance, — and it fades off gradually at the edges

72 PREVENTABLE DISEASES

into the clear whiteness or brownness of the healthy
skin, it is probably both healthy and genuine. If the
work of either fever or of art, it will generally reveal
itself as a base imitation. In eight cases out of ten of
fever, the flush, instead of being confined to this defi-
nite area, extends all over the face, even up to the
roots of the hair. The eyes, instead of being clear and
bright, are congested and heavy-lidded; and if with
these you have an increased rapidity of respiration, and
a general air of discomfort and unrest, you are fairly
safe in making a diagnosis of fever. If the first touch
of the tips of the fingers on the wrist shows a hot skin
and a rapid pulse, the diagnosis is almost as certain as
with the thermometer.

Now for two of the instances in which it most com-
monly puzzles us. The first of these is consumption ;
for here the flush, both in position and in delicacy and
gentle fading away at the proper margins, is an almost
perfect imitation of health. It, however, usually ap-
pears, not as the normal flush of health does, upon a
plump and rounded cheek, but upon a hollow and
wasted one. It rises somewhat higher upon the cheek-
bones, throwing the latter out into ghastly prominence.
The lips and the eyes will give us no clew, for the
former are red from fever, and the latter are bright from
the gentle, half-dreamy state produced by the toxins
of the disease, the so-called " spes phthisica" — the
everlasting and pathetic hopefulness of the consump-
tive. But here we call for help upon another of the fea-
tures of disease — the hand. If, instead of being cool,
and elastic, this is either dry and hot, or clammy and

THE PHYSIOGNOMY OF DISEASE 73

damp, and feels as if you were grasping a handful of
bones and nerves, and the finger-tips are clubbed and
the nails curved like claws, then you have a strong
prima facie case.

The other color condition which is apt to puzzle
us is that of the plump and comfortable middle-aged
gentleman with a fine rosy color, but a watery eye and
loose and puffy mouth, a wheezy respiration and ap-
parent excess of adipose. Here the high color is often
due to a paralytic distention of the blood-vessels of the
face and neck, and an examination of his heart and
blood-vessels shows that his prospects are anything
but as rosy as his countenance.

The varying expressions of the face of disease are
by no means confined to the countenance. In fact,
they extend to every portion of — in Trilby's immortal
phrase — "the altogether." Disease can speak most
eloquently through the hand, the carriage, the gait,
and, in a way that the patient may be entirely uncon-
scious of, the voice. These forms of expression are
naturally not so frequent as those of the face, on ac-
count of the extraordinary importance of the great
systems whose clock-dials and indices form what we
term the human countenance. But when they do occur
they are fully as graphic and more definitely and dis-
tinctively localizing.

Next in importance to the face comes the hand, and
volumes have been written upon this alone. Contain-
ing, as it does, that throbbing little blood-tube, the
radial artery, which has furnished us for centuries with
one of our oldest and most reliable guides to health

74 PREVENTABLE DISEASES

conditions, the pulse, it has played a most important
part in surface diagnoses. To this day, in fact, Arabic
and Turkish physicians in visiting their patients on
the feminine side of the family are allowed to see no-
thing of them except the hand, which is thrust through
an opening in a curtain. How accurate their diagnoses
are, based upon this slender clew, I should not like to
aver, but a sharp observer might learn much even from
this limited area.

We have — though, of course, in lesser degree — all
the color and line pictures with which we have been
dealing upon the face. Though not an index of any
special system, it has the great advantage of being our
one approach to an indication of the general muscular
tone of the body, as indicated both in its grasp and in
the poses it assumes at rest. The patient with a limp
and nerveless hand-clasp, whose hand is inclined to
lie palm upward and open instead of palm downward
and half -closed, is apt to be either seriously ill, or not
in a position to make much of a fight against the attack
of disease.

The nails furnish one of our best indices of the color
of the blood and condition of the circulation. Our
best surface test of the vigor of the circulation is to
press upon a nail, or the back of the finger just above
it, until the blood is driven out of it, and when our
thumb is removed from the whitened area to note
the rapidity with which the red freshet of blood will
rush back to reoccupy it.

In the natural growth of the nail, traveling steadily
outward from root to free edge, its tissues, at first opaque

THE PHYSIOGNOMY OF DISEASE 75

and whitish, and thus forming the little white crescent,
or lunula, found at the base of most nails, gradually
become more and more transparent, and hence pinker
in color, from allowing the blood to show through.
During a serious illness, the portion of the nail which
is then forming suffers in its nutrition, and instead of
going on normally to almost perfect transparency, it
remains opaque. And the patient will, in consequence,
carry a white bar across two or three of his nails for
from three to nine months after the illness, according
to the rate of growth of his nails. Not infrequently
this white bar will enable you to ask a patient the ques-
tion, " Did you not have a serious illness of some sort
two, three, or six months ago ?" according to the posi-
tion of the bar. And his fearsome astonishment, if he
answers your question in the affirmative, is amusing
to see. You will be lucky if, in future, he does n't in-
cline to regard you as something uncanny and little
less than a wizard.

Another of the score of interesting changes in the
hand, which, though not very common, is exceedingly
significant when found, is a curious thickening or club-
bing of the ends of the fingers, with extreme curvature
of the nails, which is associated with certain forms of
consumption. So long has it been recognized that it is
known as the " Hippocratic finger," on account of the
vivid description given of it by the Greek Father of
Medicine, Hippocrates. It has lost, however, some
of its exclusive significance, as it is found to be asso-
ciated also with certain diseases of the heart. It seems
to mean obstructed circulation through the lungs.

76 PREVENTABLE DISEASES

Next after the face and the hand would come the
carriage and gait. When a man is seriously sick he is
sick all over. Every muscle in his body has lost its
tone, and those concerned with the maintenance of the
erect position, being last developed, suffer first and
heaviest. The bowed back, the droop of the shoulders,
the hanging jaw, and the shuffling gait, tell the story
of chronic, wasting disease more graphically than
words. We have a ludicrously inverted idea of cause
and effect in our minds about " a good carriage." We
imagine that a ramrod-like stiffening of the backbone,
with the head erect, shoulders thrown back and chest
protruded, is a cause of health, instead of simply being
an effect, or one of the incidental symptoms thereof.
And we often proceed to drill our unfortunate patients
into this really cramped and irrational attitude, under
the impression that by making them look better we
shall cause them actually to become so. The head-
erect, chest-out, fingers-down-the-seam-of-your trou-
sers position of the drillmaster is little better than a
pose intended chiefly for ornament, and has to be
abandoned the moment that any attempt at movement
or action is begun.

So complete is this unconscious muscular relaxa-
tion, that it is noticeable not only in the standing and
sitting position, but also when lying down. When a
patient is exceedingly ill, and in the last state of en-
feeblement, he cannot even lie straight in bed, but col-
lapses into a curled -up heap in the middle of the bed,
the head even dropping from the pillow and falling on
the chest. Between this debacle and the slight droop

THE PHYSIOGNOMY OF DISEASE 77

of shoulders and jaw indicative of beginning trouble
there are a thousand shades of expression significant
instantly to the experienced eye.

Though more limited in their application, yet most
significant when found, are the alterations of the gait
itself. Even a maker of proverbs can tell at a glance
that "the legs of the lame are not equal." From the
limp, coupled with the direction in which the toe or
foot is turned, the tilt of the hips, the part of the foot
that strikes first, the presence or absence of pain-lines
on the face, a snap diagnosis can often be made as to
whether the trouble is paralysis, hip- joint disease, knee
or ankle mischief, of flatfoot, as your patient limps
across the room. Even where both limbs are affected
and there is no distinct limp, the form of shuffle is
often significant.

Several of the forms of paralysis have each its sig-
nificant gait. For instance, if a patient comes in with
a firm, rather precise, calculated sort of gait, " clump-
ing" each foot upon the floor as if he had struck it an
inch sooner than he had expected, and clamping it
there firmly for a moment before he lifts it again, as
though he were walking on ice, with more knee action
than seems necessary, you would have a strong sus-
picion that you had to deal with a case of locomotor
ataxia, in which loss of sensation in the soles of the feet
is one of the earliest symptoms. If so, your patient,
on inquiry, will tell you that he feels as if there were
a blanket or even a board between his soles and the
surface on which he steps. If a quick glance at the
pupils shows both smaller or larger than normal, and

78 PREVENTABLE DISEASES

on turning his face to the light they fail to contract,
your suspicion is confirmed ; while if, on asking him
to be seated and cross his legs, a tap on the great ex-
tensor tendon of the knee-joint just below the patella
fails to elicit any quick upward jerk of the foot, the
so-called "knee-kick," then you may be almost sure
of your diagnosis, and proceed to work it out at your
leisure.

On the other hand, if an elderly gentleman enters
with a curiously blank and rather melancholy expres-
sion of countenance, holding his cane out stiffly in front
of him, and comes toward you at a rapid, toddling gait,
throwing his feet forward in quick, short steps, as if,
if he failed to do so, he would fall on his face, while
at the same time a vibrating tremor carries his head
quickly from side to side, you are justified in suspect-
ing that you have to do with a case of paralysis agitans,
or shaking palsy.

Last of all, your physiognomy of disease includes
not merely its face, but its voice ; not only the picture
that it draws, but the sound that it makes. For, when
all has been allowed and discounted that the most
hardened cynic or pessimistic agnostic can say about
speech being given to man to conceal his thoughts,
and the hopeless unreliability of human testimony,
two-thirds of what your patients tell you about their
symptoms will be found to be literally the voice of the
disease itself speaking through them. They may tell
you much that is chiefly imaginary, but even imagina-
tion has got to have some physical basis as a starting-
point. They may tell you much that is clearly and

THE PHYSIOGNOMY OF DISEASE 79

ludicrously irrelevant, or untrue, on account of inac-
curacy of observation, confusion of cause and effect,
or a mental color-blindness produced by the disease
itself. But these things can all be brushed aside like
the chaff from the wheat if checked up by the picture
of the disease in plain sight before you.

In the main, the great mass of what patients tell you
is of great value and importance, and, with proper de-
ductions, perfectly reliable. In fact, I think it would
be safe to say that a sharp observer would be able to
make a fairly and approximately accurate diagnosis
in seven cases out of ten, simply by what his eye and his
touch tell him while listening to symptoms recounted
by the patient. Time and again have I seen an exam-
ination made of a reasonably intelligent patient, and
when the recital had been finished and the hawk-like
gaze had traveled from head to foot and back again,
from ear-tip to finger-nail, from eye to chest, a symp-
tom which the patient had simply forgotten to mention
would be promptly supplied ; and the gasp with which
the patient would acknowledge the truth of the sug-
gestion was worth traveling miles to see.

Of course, you pay no attention to any statement of
the patient which flatly contradicts the evidence of your
own senses. But even where patients, through some
preconceived notion, or from false ideas of shame or
discredit attaching to some particular disease, are try-
ing to mislead you, the very vigor of their efforts will
often reveal their secret, just as the piteous broken-
winged flutterings of the mother partridge reveal in-
stantly to the eye of the bird-lover the presence of the

80 PREVENTABLE DISEASES

young which she is trying to lure him away from. Only
let a patient talk enough about his or her symptoms,
and the truth will leak out.

The attitude of impatient incredulity toward the
stories of our patients, typified by the story of that
great surgeon, but greater bear, Dr. John Abernethy,
has passed, never to return. When a lady of rank came
into his consulting-room, and, having drawn off her
wraps and comfortably settled herself in her chair,
launched out into a luxurious recital of symptoms, in-
cluding most of her family history and adventures, he,
after listening about ten minutes pulled out his watch
and looked at it. The lady naturally stopped, open-
mouthed. " Madam, how long do you think it will
take you to complete the recital of your symptoms ? "
" Oh, well," — the lady floundered, embarrassed, —
"I hardly know." "Well, do you think you could fin-
ish in three-quarters of an hour?" Well, she supposed
she could, probably. " Very well, madam. I have an
operation at the hospital in the next street. Pray con-
tinue with the recital of your symptoms, and I will re-
turn in three-quarters of an hour and proceed with the
consideration of your case!"

When you can spare the time, — and no time is
wasted which is spent in getting a thorough and ex-
haustive knowledge of a serious case, — it is as good
as a play to let even your hypochondriac patients, and
those who are suffering chiefly from " nervous prosper-
ity" in its most acute form, set forth their agonies and
their afflictions in their fullest and most luxurious
length, breadth, and thickness, watching meanwhile

THE PHYSIOGNOMY OF DISEASE 81

the come and go of the lines about the face-dials, the
changes of the color, the sparkling and dulling of the
eye, the droop or pain-cramp, or luxurius loll of each
group of muscles, and quietly draw your own conclu-
sions from it all. Many and many a time, in the full
luxury of self-explanation, they will reveal to you a
clew which will prove to be the master-key to your con-
trol of the situation, and their restoration to comfort,
if not health, which you could n't have got in a week
of forceps-and-scalpel cross-examination.

In only one class of patients is this valuable aid to
knowledge absent, and that is in very young children ;
and yet, by what may'at first sight seem like a paradox,
they are, of all others, the easiest in whom to make not
merely a provisional, but a final, diagnosis. They can-
not yet talk with their tongues and their lips, but they
speak a living language in every line, every curve, every
tint of their tiny, translucent bodies, from their little
pink toes to the soft spot on the top of their downy
heads. Not only have they all the muscle-signs about
the face-dial, of pain or of comfort, but, also, these are
absolutely uncomplicated by any cross-currents of
what their elders are pleased to term "thought."

When a baby knits his brows he is not puzzling over
his political chances or worrying about his immortal
soul. He has got a pain somewhere in his little body.
When his vocal organs emit sounds, whether the gurgle
or coo of comfort, or the yell of dissatisfaction, they
are just squeezed out of him by the pressure of his own
internal sensations, and he is never talking just to hear
himself talk. Further than this, his color is so exqui-

82 PREVENTABLE DISEASES

sitely responsive to every breath of change in his in-
terior mechanism, that watching his face is almost like
observing a reaction in a test-tube, with its precipitate,
or change of color. In addition, not only will he turn
pale or flush, and his little muscles contract or relax,
but so elastic are the tissues of his surface, and so
abundant the mesh of blood-vessels just underneath,
that, under the stroke of serious illness, he will literally
shrivel like a green leaf picked from its stem, or wilt
like a faded flower.

A single glance at the tiny face on the cot pillow is
usually enough to tell you whether or not the little
morsel is seriously ill. Nothing could be further from
the truth than the prevailing impression that, because
babies can't talk, it is impossible, especially for a young
doctor, to find out what is the matter with them. If
they can't talk, neither can they tell lies, and when
they yell "Pin!" they mean pin and nothing else.

In fact, the popular impression of the puzzled dis-
comfiture of the doctor before a very small, ailing baby
is about as rational as the attitude of a good Quaker
lady in a little Western country town, who had induced
her husband to subscribe liberally toward the expenses
of a certain missionary on the West Coast of Africa.
On his return, the missionary brought her as a mark
of his gratitude a young half -grown parrot, of one of
the good talking breeds. The good lady, though de-
lighted, was considerably puzzled with the gift, and
explained to a friend of mine that she really did n't
know what to feed it, and it was n't quite old enough
to be able to talk and tell her what it wanted !

CHAPTER IV

COLDS AND HOW TO CATCH THEM

ANCIENT vibrations are hard to stop, and still
harder to control. Whether they date from our
driving back by the polar ice-sheet, together with our
titanic Big Game, the woolly rhinoceros, the mam-
moth, and the sabre-toothed tiger, from our hunting-
grounds in Siberia and Norway, or from recollections
of hunting parties pushing north from our tropical
birth-lands, and getting trapped and stormbound by
the advance of the strange giant, Winter, certain it is
that our subconsciousness is full of ancestral memo-
ries which send a shiver through our very marrow at
the mere mention of "cold" or "sleet" or "wintry
blasts."

From the earliest dawn of legend cold has always
been ranked, with hunger and pestilence and storm,
as one of the demons to be dreaded and fought.
And, at a little later date, the ancient songs and sayings
of every people have been full of quaint warnings
against the danger of a chill, a draft, wet feet, or damp
sheets. There is, of course, a bitterly substantial basis
for this feeling, as the dozens of stiffened forms whose
only winding-sheet was the curling snowdrift, or whose
coffin the frozen sleet, bear ghastly witness. It was,
however, long ago discovered that when we were
properly fed and clothed, the Cold Demon could be

84 PREVENTABLE DISEASES

absolutely defied, even in a tiny hut made out of pressed
snow and warmed by a smoky seal-blubber lamp;
that the Storm King could be baffled just by burrow-
ing into his own snowdrifts and curling up under the
crust, like an Eskimo dog. Hence, nearly all the
legends depict the hero as finally conquering the
Storm King, like Shingebis in the Song of Hiawatha.
The ancient terror, however, still clings, with a hold
the more tenacious as it becomes narrowed, to one
large group of these calamities believed to be produced
by cold, — namely, those diseases supposed to be
caused by exposure to the weather. Even here, it still
has a considerable basis in fact ; but the general trend
of opinion among thoughtful physicians is that this
basis is much narrower than was at one time supposed,
and is becoming still more restricted with the progress
of scientific knowledge. For instance, fifty years ago,
popular opinion, and even the majority of medical
belief, was that consumption and all of its attendant
miseries were chiefly due to exposure to cold. Now we
know that, on the contrary, abundance of pure, fresh,
cold air is the best cure for the disease, and foul air
and overcrowding its chief cause. An almost equally
complete about-face has been executed in regard to
pneumonia. Prolonged and excessive exposure to
cold may be the match that fires the mine, but we are
absolutely certain that two other things are necessary,
namely, the presence of the diplococcus, and a lowered
and somewhat vitiated state of bodily resistance, due
to age, overwork, underfeeding, or over-indulgence in
alcohol.

COLDS AND HOW TO CATCH THEM 85

Not only do these two diseases not occur in the land
of perpetual cold, the frozen North, except where they
are introduced by civilized visitors, — and scarce a
single death from pneumonia has ever yet occurred
in the crew of an Arctic expedition, — but it has actu-
ally been proposed to fit up a ship for a summer trip
through the Arctic regions, as a floating sanatorium
for consumptives, on account of the purity of the air
and the brilliancy of the sunlight.

There is one realm, however, where the swing of this
ancient superstition vibrates with fullest intensity, and
that is in those diseases which, as their name implies,
are still believed to be due to exposure to a lowered
temperature — "common colds." Here again it has
a certain amount of rational basis, but this is growing
less and less every day. The present attitude of thought-
ful physicians may be graphically indicated by the flip-
pant inquiry of the riddle-maker, " When is a cold not
a cold?" and the answer, "Two-thirds of the time."
This much we are certain of already : that the major-
ity of so-called "colds" have little or nothing to do
with exposure to a low temperature, that they are en-
tirely misnamed, and that a better term for them would
befouls. In fact, this proportion can be clearly and
definitely proved and traced as infections spreading
from one victim to another. The best place to catch
them is not out-of-doors, or even in drafty hallways,
but in close, stuffy, infected hotel bedrooms, sleeping-
cars, churches, and theatres.

Two arguments in rebuttal will at once be brought
forward, both apparently conclusive. One is that colds

86 PREVENTABLE DISEASES

are vastly more frequent in winter, and the other that
when you sit in a draft until you feel chilly, you inevi-
tably have a cold afterward. Both these arguments
alike, however, are based upon a misunderstanding.
The frequency of colds in winter is chiefly due to the
fact that, at this time of the year, we crowd into houses
and rooms, shutting the doors and windows in order to
keep warm, and thus provide a ready-made hothouse
for the cultivation and transmission from one to an-
other of the influenza and other bacilli. As the brilliant
young English pulmonary expert, Dr. Leonard Wil-
liams, puts it, " a constant succession of colds implies
a mode of life in which all aerial microbes are afforded
abundant opportunities." At the same time, we take
less exercise and sit far less in the open air, thus lower-
ing our general vigor and resisting power and making
us more susceptible to attack. Those who live out-of-
doors winter and summer, and who ventilate their
houses properly, even in cold weather, suffer compara-
tively little more from colds in the winter-time than
they do in summer; although, of course, the most vig-
orous individual, in the best ventilated surroundings,
will occasionally succumb to some particularly virulent
infection.

The second fact of experience, catching cold after
sitting in a draft or a chilly room until you begin to
cough or sneeze, is one to which a majority of us
would be willing to testify personally, and yet it is
based upon something little better than an illusion.
It is a well-known peculiarity of many fevers and in-
fections to begin with a chill. The patient complains

COLDS AND HOW TO CATCH THEM 87

of shiverings up and down his spine, his finger-nails
and his lips become blue, in extreme cases his teeth
chatter, 'and his limbs begin to twitch and shake, and
he ends up in a typical ague fit. The best known, be-
cause most striking, illustration is malaria, or fever
and ague, "chills and fever," as it is variously termed.
But this form of attack, milder and much slighter in
degree, may occur in almost every known infection,
such as pneumonia, typhoid, tuberculosis, scarlet
fever, measles, and influenza. It has nothing whatever
to do with either external or internal temperature ; for
if you slip a fever-thermometer under your chilling
patient's tongue, it will usually register anywhere from
102 to 105°.

This method of attack is especially common, not
only in influenza, but also in all the other so-called
"common colds." In fact, when we begin to shiver
and sneeze and hunt around for an imaginary draft or
lowering of the temperature which has caused it, we
are actually in the first stage of the development of an
infection which was contracted hours, or even days,
before.

When you begin to shiver and sneeze and run at the
eyes you are not "catching" cold; you have already
caught it long before, and it is beginning to break out
on you. Mere exposure to cold will never cause sneez-
ing. It takes a definite irritation of the nasal mucous
membrane, by gas or dust from without, or toxins from
within, to produce a sneeze.

As to mere exposure to cold weather and wet and
storm being able to produce it, it is the almost unani-

88 PREVENTABLE DISEASES

mous testimony of Arctic explorers that, during their
sojourn of from two to three years in the frozen North,
they never had so much as a sneeze or a sore throat,
even though frequently sheltered in extemporized huts,
and running short of adequate food-supply before
spring. Within a week of their return to civilization
they would begin sneezing and coughing, and catch
furious colds.

Lumbermen, trappers, hunters, and prospectors in
Alaska give similar testimony. I have talked with
scores of these pioneers, visiting them, in fact, in their
camps under conditions of wet, cold, and exposure
that would have made one afraid of either pneumonia
or rheumatism before morning, and found that, so
long as they remained up in the mountains or out in
the snow, and no case of influenza, sore throat, or cold
happened to be brought into the camp, they would
be entirely free from coughs and colds ; but that, upon
returning to civilization and sleeping in the stuffy
room of a rude frontier hotel, they would frequently
catch cold within three days.

One unusually intelligent foreman of a lumber camp
in Oregon told me that an experience of this kind had
occurred to him three different times that he could
distinctly recollect.

It is difficult to catch a cold or pneumonia unless the
bacilli are there to be caught. Boswell has embalmed
for us, in the amber of his matchless biography, the
fact that it had been noted, even in those days, that
the inhabitants of one of the Faroe Islands never had
colds in the head except on the rare occasions when

COLDS AND HOW TO CATCH THEM 89

a ship would touch there — usually not oftener than
once a year. Then, within a week, half the popula-
tion would be blowing and sneezing. The great Sam-
uel commented upon the fact at length, and advanced
the ingenious explanation that, as the harbor was so
difficult of entry, the ships could beat in only when
the wind was in a certain quarter, and that quarter
was the nor'east. Hinc illae lacrima! (Hence these
weeps !) The colds were caused by the northeast wind
of unsavory reputation ! How often the wind got into
the northeast without bringing a ship or colds he ap-
parently did not speculate.

To come nearer yet, did you ever catch cold when
camping out ? I have waked in the morning with the
snow drifting across the back of my neck, been wet
to the skin all day, and gone to bed in my wet clothes,
and slept myself dry; and have lain out all day in a
November gale, in a hollow scooped in the half-frozen
ground of the duck-marsh, and felt never a hair the
worse. Scores of similar experiences will rise up in the
minds of every camper, hunter, or fisherman. You
may catch cold during the first day or two out, before
you have got the foul city air, with its dust and bac-
teria, out of your lungs and throat, but even this
rarely happens.

How seldom one catches cold from swimming, no
matter how cold the water ; or from boating, or fishing,
— even without the standard prophylactic ; or from
picnicking, or anything that is done during a day in the
open air.

So much for the negative side of the evidence, that

90 PREVENTABLE DISEASES

colds are not often caught where infectious materials
are absent. Now for the positive side.

First of all, that typical cold of colds, influenza, or
the grip, is now unanimously admitted by authorities
to be a pure infection, due to a definite germ (the ba-
cillus influenza of Pfeiffer) and one of the most con-
tagious diseases known. Each of the great epidemics
of it — 1830-33, 1836-37, 1847-48, and, of most vivid
and unblessed memory, 1889-90 — can be traced in its
stately march completely across the civilized world, be-
ginning, as do nearly all our world-epidemics, — chol-
era, plague, influenza, etc., — in China, and spreading,
via India or Turkestan, to Russia, Berlin, London,
New York, Chicago. Moreover, its rate of progress
is precisely that of the means of travel : camel -train,
post-chaise, railway, as the case may be. The earlier
epidemics took two years to spread from Eastern Rus-
sia to New York; the later ones, forty to sixty days.
Soon it will beat Jules Verne or George Francis Train.
So intensely "catching" is it, that letters written by
sufferers have been known to infect the correspondents
who received them in a distant town, and become the
starting-point of a local epidemic.

Of course, it may be urged that when we have
proved the grip to be a definite infection, we have taken
it out of the class of "colds" altogether, and that its
bacterial origin proves nothing in regard to the rest.
But a rather interesting state of affairs developed dur-
ing the search for the true bacillus of influenza: this
was that a dozen other bacilli and cocci were discov-
ered, each of which seemed capable of causing all the

COLDS AND HOW TO CATCH THEM 91

Symptoms of the grip, though in milder form. So that
the view of the majority of pathologists now is that
these "influenzoid," or "grip-like" attacks, under
which come a majority of all common colds, are prob-
ably due to a number of different milder micro-
organisms.

The next fact in favor of the infectious character of
a cold is that it begins with a chill, followed with a
fever, runs a definite self -limited course, and, barring
complications, gets well of itself in a certain time, just
like the measles, scarlet fever, pneumonia, or any other
frank infection.

Colds are also followed by inflammations, or toxic
attacks in other organs of the body, lungs, stomach,
bowels, heart, kidneys, nerves, etc., just like diphtheria,
scarlet fever, or typhoid, only, of course, of milder form
and less frequently.

Last, but not least practically convincing, colds may
be traced from one victim to another, may "run
through" households, schools, factories, may occur
after attending church or theatre, may be checked by
isolating the sufferers; and are now most effectually
treated by the inhalation of non-poisonous germicidal
or antiseptic vapors and sprays.

One of my first experiences with this last method
occurred in a most unexpected field. An old friend,
a most interesting and intelligent German, was the
proprietor of a wild-animal depot, importing foreign
animals and birds and selling them to the zoological
gardens and circuses. I used often to drop in there
to see if he had anything new, and he would come up

92 PREVENTABLE DISEASES

to see me, to tell me his troubles and keep my dissect-
ing-table supplied with interestingly diseased dead
beasts and birds.

One day he came up in a state of great excitement,
with a very dead and dilapidated parrot in his hand.

" Choost look, Dogdor ; here 's one of dose measley
new pollies I god in from Zingapore. De rest iss
coffin' an' sneezin' to plow dere peaks off, an' all de
utter caitches iss kitchen him/*

As parrots are worth from fifteen to thirty dollars
apiece, "green" (not in color, but training), and he
had fifty or sixty in the store, the situation was distinctly
serious. Now, I was no specialist in the peculiar dis-
eases of parrots, but something had to be done, and,
with a boldness born of long practice, I drew my bow
at a venture and let fly this suggestion : —

" Try formalin ; it 's pretty fierce on the eyes and nose,
but it won't kill 'em; and, if you put a teaspoonful in
the bottom of each cage, by the time it evaporates no
germ that gets into that cage will live long enough to
do any harm."

Five days later back he came, red-eyed but trium-
phant. "Dogdor, dot vormaleen iss de pest shtuff I
effer saw. It mos' shteenk me out of de shtore, an' de
pollies nearly sneeze dere fedders off, but it shtopt de
spret, an' it 's cureenall de seek ones, an' I het a cold in
de het, an' it 's curt me."

Before using it he had fourteen cases and three
deaths ; after, only three new cases and no more deaths.
I would, however, hardly advise any human "coldic"
to try such heroic treatment offhand, for the pungency

COLDS AND HOW TO CATCH THEM 93

and painfulness of formalin vapor is something fero-
cious, though the French physicians, with character-
istic courage, are making extensive use of it for this
purpose, with excellent results under careful super-
vision.

Another curious straw pointing in the direction of the
infectious nature of • colds is the "annual cold," or
"yearly sore throat," from which many of us suffer.
When we have had it we usually feel fairly safe from
colds for some months at least, often for a year. The
only explanation that seems in the least to explain is
that colds, like other infections, confer an immunity
against another attack; only, unlike scarlet fever,
measles, smallpox, etc., this immunity, instead of for
life, is only for six months or a year. This immunity
is due to the formation in the blood of protective sub-
stances known as anti-bodies, which destroy or render
harmless the invading germs. Flabby, under-venti-
lated individuals, who are always " catching cold," have
such weak resisting powers that they form hardly
enough anti-bodies to terminate the first attack, without
having enough left to protect them from another for
more than a few weeks or months. Dr. Leonard
Williams describes chronic cold-catchers as "people
who wear flannel next their skins, . . . who know
they are in a draft because it makes them sneeze ; who,
in short, live thoroughly unwholesome, coddling lives."
Strong and vigorous individuals may form enough to
last them a year, or even two years.

Now comes the question, "What are we going to do
about it?" Obviously, we cannot "go gunning" for

94 PREVENTABLE DISEASES

these countless billions of germs, of fifteen or twenty
different species. Nor can we quarantine every one who
has a cold. Fortunately, no such radical methods are
necessary. All we have to do is to take nature's hint of
the anti-bodies and improve upon it. Healthy cells can
grow fat on a diet of such germs, and, if we keep our-
selves vigorous, clean, and well ventilated, we can prac-
tically defy the " cold " devil and all his works.

Here is the leitmotif oi the whole fascinating drama
of infection and immunity. We can study only one
phrasing here. We shall, of course, catch cold occasion-
ally, but will throw it off quickly, and probably form
anti-bodies enough to last us a year or more. How can
this be done ? First and foremost, by living and
sleeping as much as possible in the open air. This
helps in several different ways. First, by increasing
the vigor and resisting power of our bodies; second,
by helping to burn up, clean, and rid our tissues of
waste products which are poisons if retained ; third,
by greatly reducing the risks of infection.

You can't catch cold by sitting in a field exposed to
the draft from an open gate ; though I understand that
casuists of the old school of the "chill-and-damp"
theory of colds are still discussing the case of the patient
who "caught his death o' cold" by having his gruel
served in a damp basin.

The first thing to do is to get the outdoor habit. This
takes time to acquire, but, once formed, you would n't
exchange it for anything else on earth. The next thing
is to learn to sit or sleep in a gentle current of air all the
time you are indoors. You ought to feel uncomfortable

COLDS AND HOW TO CATCH THEM 95

unless you can feel air blowing across your face night
and day. Then you are reasonably sure it is fresh, and
it is the only way to be sure of it.

But drafts are so dangerous ! As the old rhyme runs,

But when a draft blows through a hole,
Make your will and mend your soul.

Pure superstition ! It just shows what 's in a name.
Call it a gentle breeze, or a current of fresh air, and no
one is afraid of it. Call it a "draft," and up go hands
and eyebrows in horror at once. One of our highest
authorities on diseases of the lungs, Dr. Norman Bridge,
has well dubbed it "The Draft Fetich." It is a fetich,
and as murderous its Moloch. The draft is a friend
instead of an enemy. What converted most of us to a
belief in the beneficence of drafts was the open-air
treatment of consumption ! Hardly could there have
been a more spectacular proof, a more dramatic defi-
ance of the bogey. To make a poor, wasted, shivering
consumptive, in a hectic one hour and a drenching
sweat the next, lie out exposed to the November
weather all day and sleep in a ten-knot gale at night !
It looked little short of murder ! So much so to some
of us, that we decided to test it on ourselves before
risking our patients.

I can still vividly recall the astonishment with which
I woke one frosty December morning, after sleeping
all night in a breeze across my head that literally made

Each particular hair to stand on end,
Like quills upon the fretful porcupine,

not only without the sign of a sniffle, but feeling as if
I 'd been made new while I slept.

96 PREVENTABLE DISEASES

Then we tried it in fear and trembling on our pa-
tients, and the delight of seeing the magic it worked !
That is an old story now, but it has never lost its charm.
To see the cough which has defied "dopes "and syrups
and cough mixtures, domestic, patent, and professional,
for months, subside and disappear in from three to ten
days ; the night sweats dry up within a week ; the appe-
tite come back ; the fever fall ; the strength and color
return, as from the magic kiss of the free air of the
woods, the prairies, the seacoast. There 's nothing else
quite like it on the green earth. Do you wonder that
we become "fresh-air fiends"?

The only thing we dread in these camps is the im-
ported "cold." Dr. Lawrence Flick was the first to
show us the way in this respect as in several others. He
put up a big sign at the entrance of White Haven Sana-
torium, "No persons suffering from colds allowed to
enter," and traced the only epidemic of colds in the
sanatorium to the visit of a butcher with the grip. I
put up a similar sign at the gate of my Oregon camp,
and never had a patient catch cold from tenting out in
the snow and "Oregon mists" until the small son of
the cook came back from the village school, shivering
and sneezing, when seven of the thirteen patients
"caught it" within a week.

What will cure a consumptive will surely not kill a
healthy man. I am delighted to say that it shows signs
of becoming a fad now, and sleeping porches are being
put on houses all over the country. No house in Cali-
fornia is considered complete without them. The
ideal bedroom is a small dressing-room, opening on

COLDS AND HOW TO CATCH THEM 97

a wide screened porch, or balcony, with a door wide
enough to allow the bed to be rolled inside during
storms or in severest weather.

Sleep on a porch, or in a room with windows on two
sides wide open, and the average living-room or office
begins to feel stuffy and "smothery" at once. Apply
the same treatment here. Learn to sit in a gentle draft,
and you '11 avoid two-thirds of your colds and three-
fourths of your headaches. It may be necessary in win-
ter to warm the draft, but don't let any patent method
of ventilation delude you into keeping your windows
shut any hour of the day or night.

On the other hand, 'don't fall into the widespread
delusion that because air is cold it is necessarily pure.
Some of the vilest air imaginable is that shut up in those
sepulchres known as "best bedrooms," which chill
your very marrow. The rheumatism or snuffles you
get from sleeping between their icy sheets comes from
the crop of bacilli which has lurked there since they
were last aired. The "no heat in a bedroom" dogma
is little better than superstition, born of those fecund
parents which mate so often, stinginess and puritanism.
Practically, the room which will never have a window
opened in it in winter is the one without any heat.

Similarly, the air in an underheated church, hall, or
theatre is almost sure to be foul. The janitor will keep
every opening closed in order to get the temperature up.
Some churches are never once decently ventilated from
December to May. The same old air, with an ever
richer crop of germs, is reheated and served up again
every Sunday. The "odor of sanctity" is the residue

98 PREVENTABLE DISEASES

of the breaths and perspiration of successive genera-
tions. Cleanliness may be next to godliness, but it is
sometimes an astonishingly long step behind it.

The next important step is to keep clean, both ex-
ternally and internally : externally, by cold bathing,
internally, by exercise. The only reason why a draft
ever hurts us is because we are full of self-poisons, or
germs. The self -poisons can be best got rid of by abun-
dant exercise in the open air and plenty of pure, cold
H2O, internally and externally.

Food has very little to do with these autotoxins, and
they are as likely to form on one diet as another. In
fact, they form normally and in states of perfect health,
and are poisonous only if retained too long. It is
simply a question of burning them up, and getting rid
of them quickly enough, by exercise, with its attend-
ant deep breathing and perspiration. The lungs are
great garbage-burners. Exercise every day till you puff
and sweat.

A blast of cold air suddenly stops the escape of these
poisons through the skin and throws them on the lungs,
liver, or kidneys. The resulting disturbance is the sec-
ond commonest form of a "cold," and covers perhaps
a third of all cases occurring. This is the cold that can
be prevented by the cold bath. Keep the skin hardened
and toned up to such a pitch that no reasonable chill
will stop it from excreting, and you are safe. Never
depend on clothing. The more you pile on, the more
you choke and "flabbify" the skin and make it ready
to "strike" on the first breath of cold air. Too heavy
flannels are cold-breeders, and chest-protectors inven-

COLDS AND HOW TO CATCH THEM 99

tions of the evil one. Trust the skin ; it is one of the
most important and toughest organs in the body, if
only given half a chance.

But the most frequent way in which drafts precipi-
tate a cold is by temporarily lowering the vital resist-
ance. This gives the swarms of germs present almost
constantly in our noses, throats, stomachs, bowels, etc.,
the chance they have been looking for — to break
through the cell barrier and run riot in the body.

So long as the pavement-cells of our mucous mem-
branes are healthy, they can keep them out indefinitely.
Lower their tone by cold, fatigue, underfeeding, and
their line is pierced in a dozen places at once. One of the
many horrifying things which bacteriology has revealed
is that our bodies are simply alive with germs, even in
perfect health. One enthusiastic dentist has discovered
and described no less than thirty-three distinct species,
each one numbering its billions, which inhabit our
gums and teeth. Our noses, our stomachs, our intes-
tines, — each boasts a similar population. Most of them
do no harm at all; indeed, some probably assist in the
processes of digestion ; others are camp-followers, living
on our leavings; others, captive enemies which have
been clubbed into peaceful behavior by our leucocyte
and anti-body police.

For instance, not a few healthy noses and throats
contain the bacillus of diphtheria and the diplococcus
of pneumonia. We are beginning to find that these last
two groups will bear watching. Like camp-followers
elsewhere, they carry knives, and are not above using
them on the wounded after dark. In fact, they have a

100 PREVENTABLE DISEASES

cheerful habit of taking a hand in any disturbance that
starts in their bailiwick, and usually on the side against
the body-cells.

Finally, while clearly realizing that the best defense
is attack, and that our chief reliance should be upon
keeping ourselves in such fighting trim that we can
"eat 'em alive" at any time, there is no sense in run-
ning easily avoidable risks, and we should keep away
from infection as far as possible. If a child comes to
school heavy-eyed, hoarse, and snuffling, the teacher
should send him home at once. He will only waste
his time attempting to study in that trim, and may infect
a score of others. Moreover, it may be remarked,
parenthetically, that these are also symptoms of the be-
ginning of measles, scarlet fever, and diphtheria, and
two-thirds of all cases of these would be sent home be-
fore they could infect any one else if this procedure
were the rule.

If your own child develops a cold, if mild, keep him
playing out-of-doors by himself ; or if severe, keep him
in bed, in a well-ventilated room, for three or four days.
He '11 get better twice as quick as if at school, and the
rest of the household will escape.

When you wake with a stuffed head and aching
bones, stay at home for a few days if possible, out of
regard for your customers, your fellow-clerks, or your
office force, as well as yourself. If one of your employ-
ees comes to work shivering, give him three days' vaca-
tion on full pay. If it runs through the force, you'll
lose five times as much in enforced sick-leaves, slow-
ness, and mistakes. Above all, don't go to any public

COLDS AND HOW TO CATCH THEM 101

gatherings, — to church, the theatre, or parties, — when
you are snuffling and coughing. You are not exactly a
joy to your beholders, even if you don't infect them.
It is advisable, and well worth the trifling trouble and
expense, to fumigate thoroughly with formalin all
churches, theatres, and schoolrooms at least once a
month. Reasonable and public-spirited precautions
of this sort are advisable, not only to avoid colds them-
selves, which are disagreeable and dangerous enough,
but because mild infections of this sort are far the com-
monest single means of making a breach in our body-
ramparts through which more serious diseases like con-
sumption, pneumonia' and rheumatism may force an
entry.

Colds do not " run into " consumption or pneumonia,
but they bear much the same relation to them that good
intentions are said to do to the infernal regions. They
release the lid of a perfect Pandora's box of distempers
— tuberculosis, pneumonia, rheumatism, bronchitis,
Bright's disease, neuritis, endocarditis. A cold is no
longer a joke. A generation ago a prominent physician
was asked by an anxious mother, " Doctor, how would
you treat a cold ?"

"With contempt, madam," replied the great man.

That day is past, and has lasted too long. Intelli-
gently regarded and handled, they are the least harm-
ful of diseases; neglected, one of the most dangerous,
because there are such legions of them. To sum up,
if you wish to revel in colds, all that is necessary is to
observe the following few and simple rules : —

Keep your windows shut.

102 PREVENTABLE DISEASES

Avoid drafts as if they were a pestilence.

Take no exercise between meals.

Bathe seldom, and in warm water.

Wear heavy flannels, chest-protectors, abdominal
bandages, and electric insoles.

Have no heat in your bedroom.

Never let anything keep you away from church, the
theatre, or parties, in winter.

Never go out-of-doors when it 's windy, or rainy, or
wet underfoot, or cold, or hot, or looks as if it was going
to be any of these.

Be just as intimate and affectionate as possible with
every one you know who has a cold. Don't neglect them
on any account.

CHAPTER V

ADENOIDS, OR MOUTH- BREATHING I THEIR CAUSE
AND THEIR CONSEQUENCES

IN all ages it has been accounted a virtue to keep
your mouth shut — chiefly, of course, upon moral
or prudential grounds, for fear of what might issue from
it if opened. Then came physiology to back up the
maxim, on the ground that the open mouth was also
dangerous on account ofwhat might be inhaled into it.
Oddly enough, in this instance, both morality and
science have been beside the mark to the degree that
they have been mistaking a symptom for a cause. This
has led us to absurd and injurious extremes in both
cases. On the moral and prudential side it has led
to such outrageous exaggerations as the well-known
and oft-quoted proverb, " Speech is silver, but silence
is golden." Articulate speech, the chiefest triumph and
highest single accomplishment of the human species,
the handmaid of thought and the instrument of pro-
gress, is actually rated below silence, the attribute of the
clod and of the dumb brute, the easy refuge of cow-
ardice and of stupidity.

Easily eight-tenths of all speech is informing, educa-
tive, helpful in some modest degree; while fully that
proportion of silence is due to lack of ideas, cowardice,
or designs that can flourish only in darkness. It is
not the abundance of words, but the scarcity of ideas,

104 PREVENTABLE DISEASES

that makes us flee from " the plugless word-spout" and
avoid the chatterbox.

Similarly, upon the physical side, because children
who breathe through the mouth are apt to have a vacant
expression, to be stupid and inattentive, undersized,
pigeon-breasted, with short upper lip and crowded
teeth, we have leaped to the conclusion that it is a
fearsome and dangerous thing to breathe through your
mouth. All sorts of stories are told about the danger-
ousness of breathing frosty air directly into the lungs.
Invalids shut themselves scrupulously indoors for
weeks and even months at a stretch, for fear of the
terrible results of a "blast of raw air" striking into
their bronchial tubes. All sorts of absurd instruments
of torture, in the form of "respirators" to tie over the
mouth and nose and "keep out the fog," are invented,
and those who have the slightest tendency to bronchial
or lung disturbances are warned upon pain of their life
to wrap up their mouths whenever they go out-of-doors.

Asa matter of fact, there is exceedingly little evi-
dence to show that pure, fresh, open air at any reason-
able temperature and humidity ever did harm when in-
haled directly into the lungs. In fact, a considerable
proportion of us, when swinging along at a lively gait on
the country roads, or playing tennis or football, or en-
gaged in any form of active sport, will be found to keep
our lips parted and to inhale from a sixth to a third of
our breath in this way, and with no injurious results
whatever. Nine-tenths of all the maladies believed to
be due to breathing even the coldest and rawest of air
are now known to be due to invading germs.

ADENOIDS, OR MOUTH-BREATHING 105

Nevertheless, mouth-breathing in all ages has been
regarded as a bad habit, and with good reason. It was
only about thirty years ago that we began to find out
why. A Danish throat surgeon, William Meyer, whose
death occurred only a few months ago, discovered,
in studying a number of children who were affected
with mouth-breathing, that in all of them were present
in the roof of the throat curious spongy growths, which
blocked up the posterior opening of the nostrils. As
this mass was made up of a number of smaller lobules,
and the tissue appeared to be like that of a lymphatic
gland, or "kernel," the name "adenoids" (gland-like)
was given to them. Later they were termed post-nasal
growths, from the fact that they lay just behind the rear
opening of the nostrils ; and these two names are used
interchangeably. Our knowledge has spread and
broadened from this starting-point, until we now know
that adenoids are the chief, yes, almost the sole primary
cause, not merely of mouth-breathing, but of at least
two-thirds of the injurious effects which have been at-
tributed to this habit.

Mouth-breathing is not simply a bad habit, a careless
trick on the part of the child. We have come to realize
that physical bad habits, as well as many mental and
moral ones, have a definite physical cause, and that no
child ever becomes a mouth-breather as long as he can
breathe comfortably through his nose.

This clears the ground at once of a considerable
amount of useless lumber in the shape of advice to
train the child to keep his mouth shut. I have even
known mothers who were in the habit of going around

106 PREVENTABLE DISEASES

after their helpless offspring were asleep and gently
but firmly pushing up the little jaw "and pressing the
lips together until some sort of an attempt at respi-
ration was made through the nostrils. Advertisements
still appear of sling-like apparatuses for holding the
jaws closed during sleep.

To attempt to stop mouth-breathing before provid-
ing abundant air-space through the nostrils is not only
irrational, but cruel. Of course, after the child has
once become a mouth-breather, even after the nostrils
have been made perfectly free, it will not at once aban-
don its habit of months or years, and disciplinary
measures of some sort may then be needed for a time.
But the hundred-times-repeated admonition, "For
heaven's sake, child, shut your mouth ! Don't go around
with it hanging open like that!" unless preceded by
proper treatment of the nostrils, will have just about
as much effect upon the habit as the proverbial water
on a duck's back. No use trying to close his mouth by
any amount of opening of your own.

Fortunately, as does not always happen, with our
discovery of the cause has come the knowledge of the
cure ; and we are able to say with confidence that, wide-
spread and serious as are disturbances of health and
growth associated with mouth-breathing, they can be
absolutely prevented and abolished.

What, then, is the cause of this nasal obstruction, and
when does it begin to operate ? The primary cause is
catarrhal inflammation, with swelling and thickening of
the secretions, and it may begin to operate anywhere
from the seventh month to the seventh year. A neg-

ADENOIDS, OR MOUTH-BREATHING 107

lected attack, or series of attacks, of " snuffles," colds
in the head, catarrhs, in infants and young children,
will set up a slow inflammation of this glandular mass
at the back of the nostrils — a tonsil, by the way —
and start its enlargement.

Whether we know anything about adenoids them-
selves or not, we are all familiar with their handiwork.
The open mouth, giving a vacant expression to the
countenance, the short upper lip, the pinched and
contracted nostrils, the prominent and irregular teeth,
the listless expression of the eyes, the slow response to
request or demand, we have seen a score of times in
every school room. Coupled with these facial features
are apt to be found on closer investigation a lack of
interest in both work and play, an impaired appetite,
restless sleep, and a curious general backwardness of
development, both bodily and mental, so that the child
may be from one to four inches below the normal
height for his years, from five to fifteen pounds under
weight, and from one to three grades behind his proper
school position. Very often, also, his chest is inclined
to be narrow, the tip of his breastbone to be sunken,
and his abdomen larger in girth than his chest. Is it
possible that the mere inhaling of air directly into the
lungs, even though it be imperfectly warmed, moist-
ened, and filtered, as compared with what it would be
if drawn through the elaborate "steam-coils" in the
nostrils for this purpose, can have produced this array
of defects ? It is incredible on the face of it and un-
founded in fact. Fully two-thirds of these can be
traced to the direct influence of the adenoids.

108 PREVENTABLE DISEASES

These adenoids, it may briefly be stated, are the re-
sult of an enlargement of a tonsil, or group of small ton-
sils, identical in structure with the well-known bodies
of the same name which can be seen on either side
of the throat. They have the same unfortunate faculty
as the other tonsils for getting into hot water, flaring up,
inflaming, and swelling on the slightest irritation. And,
unfortunately, they are so situated that their capacity
for harm is far greater than that of the other tonsils.
They seem painfully like the chip on the shoulder of
a fighting man, ready to be knocked off at the lightest
touch and plunge the whole body into a scrimmage.
Their position is a little difficult to describe to one not
familiar with the anatomy of the throat, especially as
they cannot be seen except with a laryngeal mirror;
but it may be roughly stated as in the middle of the
roof of the throat, just at the back of the nostrils,
and above the soft palate. From this coign of vantage
they are in position to produce serious disturbances
of two of our most important functions, — respiration
and digestion, — and three out of the five senses, —
smell, taste, and hearing.

We will begin with their most frequent and most se-
rious injurious effect, though not the earliest, — the
impairment of the child's power of attention and intel-
ligence. So well known is their effect in this respect
that there is scarcely an intelligent and progressive
teacher nowadays who is not thoroughly posted on
adenoids. Some of them will make a snap diagnosis as
promptly and almost as accurately as a physician ; and
when once they suspect their presence, they will leave

ADENOIDS, OR MOUTH-BREATHING 109

no stone unturned to secure an examination of the child
by a competent physician, and the removal of the
growths, if present. They consider it a waste of time
to endeavor to teach a child weighted with this handi-
cap. How keenly awake they are to their importance
is typified by the remark of a prominent educator five
or six years ago : —

"When I hear a teacher say that a child is stupid,
my first instinctive conclusion is either that the child
has adenoids, or that the teacher is incompetent."

The lion's share of their influence upon the child's
intelligence is brought about in a somewhat unexpected
and even surprising manner, and that is by the effects
of the growths upon his hearing. You will recall that
this third tonsil was situated at the highest point in the
roof of the pharynx, or back of the throat. The first
effect of its enlargement is naturally to block the pos-
terior opening of the nostrils. But it has another most
serious vantage-ground for harm in its peculiar position.
Only about three-fourths of an inch below it upon either
side open the mouths of the Eustachian tubes, the little
funnels which carry air from the throat out into the
drum-cavity of the ear. You have frequently had prac-
tical demonstrations of their existence, by the well-
known sensation, when blowing your nose vigorously,
of feeling something go "pop" in the ear. This sensa-
tion was simply due to a bubble of air being driven
out through this tube from the back of the throat,
under pressure brought to bear in blowing the nose.
The luckless position of the third tonsil could hardly
have been better planned if it had been devised for the

110 PREVENTABLE DISEASES

special purpose of setting up trouble in the mouths of
these Eustachian tubes.

Just as soon as the enlargements become chronic,
they pour out a thick mucous secretion, which quickly
becomes purulent, or, in the vernacular, "matter."
This trickles down on both sides of the throat, and
drains right into the open mouth of the Eustachian
tube. Not only so, but these Eustachian tubes are the
remains of the first gill-slits of embryonic life, and, like
all other gill-slits, have a little mass of this same lym-
phoid or tonsilar tissue surrounding them. This also
becomes infected and inflamed, clogs the opening, and
one fatal day the inflammation shoots out along the tube,
and the child develops an attack of earache. At least
two-thirds of all cases of earache, and, indeed, five-
sixths of all cases of deafness in children, are due to
adenoids.

Earache is simply the pain due to acute inflammation
in the small drum-cavity of the ear. This in the large
majority of cases will subside and drain back again
into the throat through the Eustachian tube. In a fair
percentage of instances, however, it will break in the
opposite direction, and we have the familiar ruptured
drum and discharge from the ear. In either case the
drum becomes thickened, so that it can no longer
vibrate properly ; the delicate little chain of bones be-
hind it, like the levers of a piano, becomes clogged,
and the child becomes deaf, whether a chronic dis-
charge be present or not.

This is the secret of his "inattention," his "indiffer-
ence," — even of his apparent disobedience and re-

ADENOIDS, OR MOUTH-BREATHING 111

belliousness. What other children hear without an
effort he has to strain every nerve to catch. He mis-
understands the question that is asked of him, makes an
absurd answer, and is either scolded or laughed at. It
is n't long before he falls into the attitude : " Well, I
can't get it right, anyhow, no matter how I try, so I
don't care." Up to five or ten years ago the puzzled
and distracted teacher would simply report the child
for stupidity, indifference, and even insubordination.
In nine cases out of ten, when children are naughty or
stupid, they are really sick.

Not content with dulling one of the child's senses,
these thugs of the body-politic proceed to throttle two
others — smell and taste. Obviously the only way of
smelling anything is to sniff its odor into your nose.
And if this be more or less, or completely, blocked up,
and its delicate mucous membranes coated with a
thick, ropy discharge, you will not be able to distin-
guish anything but the crudest and rankest of odors.
But what has this to do with taste ? Merely that two-
thirds of what we term "taste" is really smell. Seal
the nostrils and you can't " tell chalk from cheese," not
even a cube of apple from a cube of onion, as scores of
experiments have shown. We all know how flat tea,
coffee, and even our own favorite dishes taste when we
have a bad cold, and this, remember, is the permanent
condition of the palate of the poor little mouth-breather.
No wonder his appetite is apt to be poor, and that even
what food he eats will not produce a flow of " appetite
juice" in the stomach, which Pavloff has shown to be
so necessary to digestion. No wonder his digestion is

112 PREVENTABLE DISEASES

apt to go wrong, ably assisted by the continual drip of
the chronic discharge down the back of his throat ; his
bowels to become clogged and his abdomen distended.

But the resources for mischief of this pharyngeal
"Old Man of the Sea" are not even yet exhausted.
Next comes a very curious and unexpected one. We
have all heard much of "the struggle for existence"
among plants and animals, and have had painful
demonstrations of its reality in our own personal expe-
rience. But we hardly suspected that it was going on in
our own interior. Such, however, is the case ; and when
once one organ or structure falls behind the others
in the race of growth, its neighbors promptly begin
to enrcoach upon and take advantage of it. Emer-
son was right when he said, " I am the Cosmos," the
universe.

Now, the mouth and the nose were originally one
cavity. As Huxley long ago remarked, "When Nature
undertook to build the skull of a land animal she was
too lazy to start on new lines, and simply took the old
fish-skull and made it over, for air-breathing purposes."
And a clumsy job she made of it !

It may be remarked, in passing, that mouth-breath-
ing, as a matter of history, is an exceedingly old and
respectable habit, a reversion, in fact, to the method
of breathing of the fish and the frog. " To drink like
a fish" is a shameful and utterly unfounded aspersion
upon a blameless creature of most correct habits and
model deportment. What the poor goldfish in the bowl
is really doing with his continual "gulp, gulp!" is
breathing — not drinking.

ADENOIDS, OR MOUTH-BREATHING 113

This remodeling starts at a very early period of our
individual existence. A horizontal ridge begins to grow
out on either side of our mouth-nose cavity, just above
the roots of the teeth. This thickens and widens into
a pair of shelves, which finally, about the third month
of embryonic life, meet in the middle line to form the
hard palate or roof of the mouth, which forms also the
floor of the nose. Failure of the two shelves to meet
properly causes the well-known "cleft-palate, "and, if
this failure extends forward to the jaw, "hare-lip." In
the growth of a healthy child a balance is preserved
between these lower and upper compartments of the
original mouth-nose cavity, and the nose above growing
as rapidly in depth and in breadth as the mouth be-
low, the horizontal partition between — the floor of
the nose and the roof of the mouth — is kept compara-
tively flat and level. In adenoids, however, the nostrils
no longer being adequately used, and consequently
failing to grow, and the mouth cavity below growing
at the full normal rate, it is not long before the mouth
begins to encroach upon the nostrils by pushing up the
partition of the palate. As soon as this upward bulge
of the roof of the mouth occurs, then there is a diminu-
tion of the resistance offered by the horizontal healthy
palate to the continual pressure of the muscles of the
cheeks and of mastication upon the sides of the upper
jaw, the more readily as the tongue has dropped
down from its proper resting position up in the roof of
the mouth. These are pushed inward, the arch of the
jaw and of the teeth is narrowed, the front teeth are
made to project, and, instead of erupting, with plenty

114 PREVENTABLE DISEASES

of room, in even, regular lines, are crowded against and
overlap one another.

When from any cause the lower jaw habitually hangs
down, as in the open mouth, it tends to be thrown
slightly forward in its socket. Then, when the jaws
close again, the arches of the upper and lower teeth
no longer meet evenly. Instead of "locking" at almost
every point, as they should, they overlap, or fall behind,
or inside, or outside, of each other. So that instead of
every tooth meeting its fellow of the jaw above evenly
and firmly, they strike at an angle, slip past or even
miss one another, and thus increase the already ex-
isting irregularity and overlapping. Each individual
tooth, missing its best stimulus to healthy growth and
vigor, firm and regular pressure and exercise against
its fellow in the jaw above or below, gets a twist in its
socket, wears away irregularly, and becomes an easy
prey to decay, while from failure of the entire upper and
lower arches of the teeth to meet squarely and press
evenly and firmly against one another, the jaws fail to
expand properly and the tendency to narrowing of the
tooth-arches and upward vaulting of the palate is in-
creased.

In short, we are coming to the conclusion that from
half to two-thirds of all cases of "crowded mouth,"
irregular teeth, and high-arched palate in children are
due to adenoids. Progressive dentists now are insisting
upon their little patients, who come to them with these
conditions, being examined for adenoids, and upon
the removal of these, if found, as a preliminary measure
to mechanical corrective treatment. Cases are now on

ADENOIDS, OR MOUTH-BREATHING 115

record of children with two, three, or even four genera-
tions of crowded teeth and narrow mouths behind
them, but who, simply by being sharply watched for
nasal obstruction and the symptoms of adenoids, by the
removal of these latter as soon as they have put in an
appearance, have grown up with even, regular, well-
developed teeth and wide, healthy mouths and jaws.
Unfortunately, attention to the adenoids will not re-
move these defects of the jaws and teeth after they have
been produced. But, if the child be under ten, or even
twelve, years of age, their removal may yet do much
permanently to improve the condition, and is cer-
tainly well worth while on general principles.

Take care of the nose, and the jaws will take care of
themselves. An ounce of .adenoids-removal in the
young child is worth a pound of orthodontia — teeth-
straightening — in the boy or girl ; though both are
often necessary.

The dull, dead tone of the voice in these children is,
of course, an obvious effect of the blocked nostrils.
Similarly, the broken sleep, with dreams of suffocation
and of " Things Sitting on the Chest," are readily ex-
plained by the desperate efforts that the little one makes
to breathe through clogging nostrils, in which the dis-
charges, blown and sneezed out in the daytime, dry and
accumulate during sleep, until, half-suffocated, it "lets
go" and draws in huge gulps of air through the open
mouth. No child ever became a mouth-breather from
choice, or until after a prolonged struggle to continue
breathing through its nose.

This brings us to the question, What are these ade-

116 PREVENTABLE DISEASES

noids, and how do they come to produce such serious
disturbances ? This can be partially answered by say-
ing that they are tonsils and with all a tonsil's suscep-
tibility to irritation and inflammation. But that only
raises the further question, What is a tonsil ? And to
that no answer can be given but Echo's. They are one
of the conundrums of physiology. All we know of them
is that they are not true glands, as they have neither
duct nor secretion, but masses of simple embryonic
tissue called lymphoid, which has a habit of grouping
itself about the openings of disused canals. This is
what accounts for their position in the throat, as they
have no known useful function. The two largest, or
throat-tonsils, surround the inner openings of the sec-
ond gill-slits of the embryo ; the lingual tonsil, at the
base of the tongue below, encircles the mouth of the
duct of the thyroid gland (the goitre gland) ; and our
own particular Pandora's Box above, in the roof of the
pharynx, is grouped about the opening of another dis-
used canal, which performs the singular and appar-
ently most uncalled-for office of connecting the cavity
of the brain with the throat. They can all of them be
removed completely without any injury to the general
health, and they all tend to shrink and become smaller
— in the case of the topmost, or pharyngeal, almost
disappear — after the twelfth or fourteenth year.

Not only have they an abundant crop of troubles of
their own, as most of us can testify from painful ex-
perience, but they serve as a port of entry for the germs
of many serious diseases, such as tuberculosis, rheuma-
tism, diphtheria, and possibly scarlet fever. They ap-

ADENOIDS, OR MOUTH-BREATHING 117

pear to be a strange sort of survival or remnant, — not
even suitable for the bargain-counter, — a hereditary
leisure class in the modern democracy of the body, a
fertile soil for all sorts of trouble.

Here, then, we have this little bunch of idle tissue,
about the size of a small hazelnut, ready for any mis-
chief which our Satan-bacilli may find for its hands to
do. A child kept in a badly ventilated room inhales into
his nostrils irritating dust or gases, or, more commonly
yet, the floating germs of some one or more of those
dozen mild infections which we term " a common cold."
Instantly irritation and swelling are set up in the ex-
quisitely elastic tissues of the nostrils, thick, sticky
mucous, instead of the normal watery secretion, is
poured out, the child begins to sneeze and snuffle and
"run at the nose," and either the bacteria are carried
directly to this danger sponge, right at the back of the
nostrils, or the inflammation gradually spreads to it.
The mucous membrane and tissues of the nose have an
abundance of vitality, — like most hard workers, —
and usually react, overwhelm, and destroy the invading
germs, and recover from the attack; but the useless
and half-dead tissue of the pharyngeal tonsil has much
less power of recuperation, and it smoulders and in-
flames, though ultimately, perhaps, it may swing round
to recovery. Often, however, a new cold will be caught
before this has fully occurred, and then another one a
month or so later, until finally we get a chronically
thickened, inflamed, and enlarged condition of this in-
teresting, but troublesome, body. What its capabili-
ties are in this respect may be gathered from the fact

118 PREVENTABLE DISEASES

that, while normally of the size of a small hazelnut, it is
no uncommon thing to find a mass which absolutely
blocks up the whole of the upper part of the pharynx,
and may vary from the size of a robin's egg to that of a
large English walnut, or even a small hen's egg, accord-
ing to the age of the child and the size of the throat.

Dirt has been defined as "matter out of place,"
and the pharyngeal tonsil is an excellent illustration.
Nature is said never to make mistakes, but she is apt to
be absent-minded at times, and we are tracing now not
a few of the troubles that our flesh is heir to, to little
oversights of hers — scraps of inflammable material
left lying about among the cogs of the body-machine,
such as the appendix, the gall-bladder, the wisdom
teeth, and the tonsils, One day a spark drops on them,
or they get too near a bearing or a "hot-box," and, in
a flash, the whole machine is in a blaze.

Never neglect snuffles or "cold in the head" in a
young child, and particularly in a baby. Have it treated
at once antiseptically, by competent hands, and learn
exactly what to do for it on the appearance of the earli-
est symptoms in the future, and you will not only save
the little ones a great deal of temporary discomfort and
distress, — for it is perfect torment to a child to breathe
through its mouth at first, — but you will ward off
many of the most serious troubles of infancy and child-
hood. We can hardly expect to prevent all development
of adenoids by these prompt and painless stitches in
time, for some children seem to be born peculiarly
subject to them, either from the inheritance of a par-
ticular shape of nose and throat, — "the family nose,"

ADENOIDS, OR MOUTH-BREATHING 119

as it has been called, — or from some peculiar spongi-
ness and liability to inflammation and enlargement of all
these tonsilar or lymphoid "glands" and " kernels" of
the body generally — the old " lymphatic tempera-
ment."

We are, however, now coming to the opinion that
this so-called "hereditary" narrow nose, short upper
lip, and high-arched palate are, in a large percentage
of cases, the result of adenoids in infancy in each suc-
cessive generation of parents and grandparents. At all
events, there are now on record cases of children whose
parents, grandparents, and great -grandparents are
known to have been nfouth-breathers, and who have
on that account been sharply watched for the possible
development of adenoids in early life, and these re-
moved as soon as they appeared, and they have grown
up with well-developed, wide nostrils, broad, flat pal-
ates, and regular teeth, overcoming "hereditary de-
fect" in a single generation.

Curiously enough, their origin and ancestral relations
may have an important practical bearing, even in the
twentieth century. At the upper end of this curious
throat-brain canal lies another mass, the so-called pit-
uitary body. This has been found to exert a profound
influence over development and growth. Its enlarge-
ment is attended by giantism and another curious giant
disease in which the hands, feet, and jaws enlarge enor-
mously, known as acromegaly. It also pours into the
blood a secretion which has a powerful effect upon
both the circulation and the respiration. It is found
shrunken and wasted in dwarfs. Some years ago it was

1 120 PREVENTABLE DISEASES

suggested by my distinguished friend, the late Dr.
Harrison Allen, and myself, that some of the extraor-
dinary dwarfing and growth-retarding effects of ade-
noids might be due to a reflex influence exerted on their
old colleague, the pituitary body. This view has found
its way into several of the textbooks. Blood is thicker
than water, and old ancestral vibrations will some-
times be set up in most unexpected places.

Now comes the cheerful side of the picture. I should
have hesitated to draw at such full length and in such
lugubrious detail the direful possibilities and injurious
effects of adenoids if its only result could have been to
arouse apprehensions which could not be relieved.

Fortunately, just the reverse is the case, and there
are few conditions affecting the child, so common and
such a fertile source of all kinds of mischief, and at the
same time so completely curable, and whose cure will
be attended by such gratifying improvement on the part
of the little sufferer. In the first place, as has been said,
their formation may usually be prevented altogether
by intelligent and up-to-date hygienic care of the nose
and the throat. In the second place, even after they
have occurred and developed to a considerable degree,
they can be removed by a trifling and almost painless
operation, and, if taken early enough, all their injurious
effects overcome. If, however, they have been neglected
too long, so that the child has passed the eighth or ninth
year before any interference has been attempted, and
still more, of course, if it has passed the twelfth or
thirteenth year, then only a part of the disturbances
that have been caused can be remedied by their removal.

ADENOIDS, OR MOUTH-BREATHING 121

So soft and pulpy are these growths, so poorly supplied
with blood-vessels or nerves, and so slightly connected
with the healthy tissues below them, that they may,
in skilled hands, be completely removed by simply
scraping with a dull surgical spoon (curette) or curved
forceps, but never anything more knife-like than this.
In fact, in the first seven years of life, when their re-
moval is both easiest and will do most good, it is hardly
proper to dignify the procedure by the name of an
operation. It is attended by about the same degree
of risk and of hemorrhage as the extraction of a tooth,
and by less than half the amount of pain.

But, trifling and freelfrom danger as is the operation,
there is nothing in the entire realm of surgery which is
followed by more brilliant and gratifying results. It
seems almost incredible until one has seen it in half a
dozen successive cases. Not merely doctors, but teach-
ers and nurses, develop a positive enthusiasm for it.
This was the operation that led to the comical, but
pathetic, "Mothers' Riots" in the New York schools.
The word went forth, "The Krishts are cutting the
throats of your children"; and, with the shameful
echoes of Kishineff ringing in their ears, the Yiddish
mothers swarmed forth to battle for the lives of their
offspring.

It is no uncommon thing to have a child of seven
jump three to five inches in height, six to twelve pounds
in weight, and one to three grades in his schooling,
within the year following the operation. Ten years
more of intelligence and hygienic teaching should see
this scourge of childhood completely wiped out, or at

122 PREVENTABLE DISEASES

least robbed of its possibilities for harm. When this is
done, at least two-thirds of all cases of deafness, more
than half of all cases of arrested development, and
three-fourths of those of backwardness in children will
disappear.

CHAPTER VI

TUBERCULOSIS, A SCOTCHED SNAKE

ONE of the darling habits of humanity is to dis-
cover that we are facing a crisis. One could safely
offer a large prize for a group of ten commencement
orations, or political platforms, at least a third of which
did not announce this momentous fact. Either we are
facing it or it confronts us, and unutterable things will
happen unless we" gird up our loins,"and vote the right
' ticket. An interesting feature about these loudly her-
alded crises is that they hardly ever "crise." The real
crisis either strikes us so hard that we never know what
hit us, or is over before we recognize that anything was
going to happen. And most of our reflections about it
are after ones — trying to explain what caused it. In
fact, in public affairs, as in medicine, a crisis is a sign of
recovery. Its occurrence is an indication that nature is
preparing to throwoff the disease. Nowhere is this truth
more vividly illustrated than in the tuberculosis situa-
tion. When, about thirty years ago, the world began to
awake from its stupor of centuries, and to realize that
this one great disease alone was killing one-seven!h of all
people born under civilization, and crippling as many
more ; that its killed and wounded every year cast in the
shade the bloodiest wars ever waged, and that it was ap-

124 PREVENTABLE DISEASES

parently caused by the civilization which it ravaged, —
no wonder that we were appalled at the outlook.

Here was a disease of civilization, caused by the
conditions of that civilization. Could it be cured with-
out destroying its cause and reverting to barbarism ?
Yet this very apprehension was a sign of hope, a pro-
mise of improvement. That we were able to feel it was
a sign that we were shaking off the old fatalistic attitude
toward disease, — as inevitable or an act of Providence.
It was brought about by the more accurate and sys-
tematic study of disease. We had long been sadly
familiar with the fact that death by consumption, by
"slow decline," by "wasting" or "slow fever," was
frightfully common. "To fall into a decline" and die
was one of the standard commonplaces of romantic
literature. But that was quite different from knowing
in cold, hard figures and inescapable percentages ex-
actly how many of the race were killed by it. It is one
of the striking illustrations of the advantages of good
bookkeeping. Boards and departments of health had
just fairly got on their feet and started an accurate
system of state accounts in matters of deaths and
births. We were beginning to recognize national
health as an asset, and to scrutinize its fluctuations
with keen interest accordingly.

We may decry statistics as much as we like, but
when we see the effects of a disease set down in cold
columns of black and white we have no longer any idea
of submitting to it as inevitable. We are going to get
right up and do some fighting. "One-seventh of all
the deaths" has literally become the war cry of our

TUBERCULOSIS 125

new Holy War against tuberculosis. Still another stir-
ring phrase of inestimable value in rousing us from our
torpor was that coined by the brilliant and lovable
physician-philosopher, Oliver Wendell Holmes: "The
Great White Plague of the North." This vivid epithet,
abused as it may have been in later years, was of enor-
mous service in fixing the public mind on consumption
as a definite, individual disease, something to be fought
and guarded against. Before that, we had been in-
clined to look upon it as just a natural failing of the
vital forces, a thing that came from within, and was in
no sense caused frooorwithout. The fair young girl, or
the delicate boy whose vitality was hardly sufficient
to carry him through the stern battle of life, under
some slight shock, or even mental disappointment,
would sink into a decline, gradually waste away, and
die. What could be done in such a case, except to bow
in submission to the inscrutable ways of Providence ?

It seems incredible now, but such was the light in
which smallpox was regarded by physicians of the
Arabian and mediaeval schools : a natural oozing forth
of "peccant humors" in the blood of the young, a dis-
agreeable, but perfectly natural, and even necessary,
process. For if the patient did not get rid of these hu-
mors either he would die or his growth would be seri-
ously impaired. Now smallpox has become little more
than a memory in civilization, and consumption is due
to follow its example.

Sanitary pioneers had already begun casting about
eagerly for light upon the influence of housing, of
drainage, of food, in the causation of tuberculosis,

126 PREVENTABLE DISEASES

when a new and powerful weapon was suddenly placed
in their hands by the infant science of bacteriology.
This was the now world-famous discovery by Robert
Koch that consumption and other forms of tuberculo-
sis were due to the attack of a definite bacillus. No
tubercle bacillus — no consumption.

At first sight this discovery appeared to be anything
but encouraging. In fact, it seemed to make the situ-
ation and the outlook even more hopeless. And when
within a few years it was further demonstrated in rapid
succession that most of the diseases of the spine in chil-
dren, of the group of symptoms associated with en-
larged glands or kernels in the neck and known as
"scrofula" or struma, most cases of hip-joint disease,
of white swelling of the knee, a large percentage of
chronic ulcerations of the skin known as lupus, a com-
mon form of fatal bowel disease in children, and many
instances of peritonitis in adults, together with fully
half of the fatal cases of convulsions in children, were
due to the activity of this same ubiquitous bacillus, it
looked as if the enemy were hopelessly entrenched
against attack. And when it was further found that
a similar bacillus was almost as common a cause of
death and disease in cattle, particularly dairy cattle,
and another in domestic fowls, it looked as if the
heavens above and the earth beneath were so thickly
strewn and so hopelessly infested with the germs that
to war against them, or hope to escape from them,
was like fighting back the Atlantic tides with a broom.

But this chill of discouragement quickly passed.
Our foe had come down out of the clouds, and was

TUBERCULOSIS 127

spread out in battle array before us, in plain sight on
the level earth. We were ready for the conflict, and
proposed to " fight it out on this line if it takes all sum-
mer." It was not long before we began to see joints in
the enemy's armor and weaknesses in his positions.
Then, when we lowered our field-glasses and turned to
count our forces and prepare for the defense, we dis-
covered with a shock of delighted relief that whole
regiments of unexpected reinforcements had come up
while we were studying the enemy's position. These
new allies of ours were three of the great, silent forces
of nature, which had fallen into line on either side
and behind us, without hurry and without excitement,
without even a bugle-blast to announce their coming.

The first was the great resisting power and vigor of
the human organism, which we had gravely underes-
timated. The second, that power of adaptation to new
circumstances, including even the attack of infectious
diseases, which we call "survival of the fittest." The
third, that great, sustaining, conservative power of
nature — heredity. More cheering yet, these forces
came, not merely fully armed, but bearing new wea-
pons fitted for our hands. The vigor and unconquer-
able toughness of the human animal presented us with
three glittering weapons, sunshine, food, and fresh air.

"If the deadly bacillus breaks through the lines,
put me in the gap ! With these weapons, with this triad,
I will engage to hurl him back, shattered and broken."
" Equip your vanguard with them, and the enemy will
never break the line."

The survival of the fittest held out to us two weapons

128 PREVENTABLE DISEASES

of strange and curious make, one of them labeled " im-
munity," the other "quarantine." "Give me a little
time," she said, "and with the first of these I will make
seven-tenths of the soldiers in your army proof against
the spears of the enemy, as Achilles was when dipped
in the Styx. With the other, surround and isolate every
roving band of the enemy that you can find ; drive him
out of the holes and caves in which he lives, into the
sunlight. Hold him in the open for forty-eight hours,
and he will die of light-stroke and starvation. Divide
and conquer ! "

These reinforcements of ours have proved no mere
figure of speech. They have won many a battle for us
already upon the tented field. They have not merely
made good their promises, but gone beyond them, and
we are only .just beginning to appreciate their true
worth, and how absolutely we can rely upon them.

The first outpost of the enemy was captured with the
sunshine-food-air weapons, and a glorious victory it
was, — great in itself, and even more important for its
moral effect and its encouragement for the future. To
pronounce an illness " consumption " had been from
time immemorial equivalent to signing a death-war-
rant. Even the doctors could hardly believe it, when
the first open-air enthusiasts began to claim that they
had actually cured cases of genuine consumption. For
long there was a tendency to mutter in the beard,
"Well, it was n't genuine consumption, or it would n't
have got better."

But after a period of incredulity this gave way to de-
lighted confidence. The open-air method would cure,

TUBERCULOSIS 129

and did cure, and the patients remained cured for years
afterward. Our first claims were barely for twenty-five
or thirty per cent of the threatened victims. Then we
were able to increase it to fifty per cent ; sixty, seventy,
and finally eighty were successively reached. But with
the increase of our power over the cure of this disease
came a realization of our knowledge of its limitations.
It quickly proved itself to be no sovereign and uni-
versal panacea, which would cure all cases, however
desperate, or however indiscriminately it was applied.
And emphatically it had to be mixed with brains, on
the part both of the pjiysician and of the patient.

In the first place, the likelihood of a cure depended,
with almost mathematical certainty, upon the earliness
of the stage at which it was begun. Eight or ten years
ago the outlook crystallized itself into the form which it
has practically retained since : of cases put under treat-
ment in the very early stage, from seventy to ninety per
cent were practical cures ; of ordinary so-called " first-
stage" cases, sixty to seventy per cent; second-stage
cases, or those in whom the disease was well developed,
thirty to sixty per cent ; and well-advanced cases, fifteen
to thirty per cent of apparent cures. The crux of the
whole proposition lies in the early recognition of the dis-
ease by the physician, and the prompt acceptance of the
diagnosis by the patient, and his willingness to drop
everything and fight intelligently and vigorously for
his life. Physicians are now thoroughly awake on this
point, and are concentrating their most careful atten-
tion and study upon methods of recognition at the
earliest possible stages. At the same time those mag-

130 PREVENTABLE DISEASES

nificent associations for the study and prevention of
tuberculosis, international, national, state, and local, —
the greatest of which, the International Tuberculosis
Congress, has just honored America by meeting in
Washington, — are straining every nerve to educate
the public to understand the importance of recognizing
the earliest possible symptoms of this disease, no mat-
ter how trivial they may appear, and making every
other consideration bend to the fight.

This new Word of Power, the open-air treatment,
alone has transformed one of the most hopeless, most
pathetic, and painful fields of disease into one of the
most cheerful and hopeful. The vantage-ground won
is something enormous. No longer need the family phy-
sician hang back, in dread and horror, from allowing
himself even to recognize that the slow loss of weight,
the increasing weakness, the flushed evening cheek, and
the restless sleep, are signs of this dread malady. In-
stead of shrinking from pronouncing the patient's
doom, he knows now that he has everything to gain
and nothing to lose by promptly warning him of his
danger, even while it is still problematical. On the
other hand, the patient need no longer recoil in horror
when told that he has consumption, and either go
home to set his house in order and make his will, or
hunt up another medical adviser who will take a more
cheerful view of his case. All that he has to do is to
turn and fight the disease vigorously, intelligently, per-
sistently, with the certain knowledge that the chances
are five to one in his favor ; and that 's a good fighting
chance for any one.

TUBERCULOSIS 131

Even should there be reasonable ground for doubt as
to the positive nature of the disease, he has nothing to
lose and everything to gain by taking the steps required
to cure it. There is nothing magical or irrational, least
of all injurious, in any way about them. Simply rest,
abundant feeding, and plenty of fresh air. Even if the
bacillus has not yet lodged in his tissues, this treatment
will relieve the conditions of depression from which he
is suffering, and which would sooner or later render
him a favorable lodging-place for this omnipresent,
tiny enemy.

If he has the disease the treatment will cure it. If he
has n't got it, it will prevent it; and the gain in vigor,
weight, and general efficiency will more than pay him
for the time lost from his business or his study. It al-
ways pays to take time to put yourself back into a con-
dition of good health and highest efficiency.

It was early recognized that the campaign could not
be won with this weapon alone. Inexpressibly valuable
and cheering as it was, it had obvious limitations. Th,e
first of these was the obvious reflection that it was idle
to cure even eighty per cent of all who actually devel-
oped tuberculosis, unless something were done to stop
the disease from developing at all. "Eighty per cent of
cures," of course, sounds very encouraging, especially
by contrast with the almost unbroken succession of
deaths before. But even a twenty per cent mortality
from such a common disease, if it were to proceed un-
checked, would make enormous inroads every year
upon our national vigor.

Secondly, it was quickly seen that those who recov-

132 PREVENTABLE DISEASES

ered from the disease still bore the scars; that while
they might recover a fair degree of health and vigor,
yet they were always handicapped by the time lost and
the damage inflicted by this slow and obstinate malady ;
that many of them, while able to preserve good health
under ideal conditions, were markedly and often dis-
tressingly limited in the range of their business activi-
ties for years after, and even for life. Finally, that as
these cases were followed further and further, it was
found that even after becoming cured they were sadly
liable to relapse under some unexpected strain, or to
slacken their vigilance and drop back into their former
bad physical habits ; while the conviction began to grow
steadily upon men who had devoted one, two, or more
decades to the study of this disease in the localities
most resorted to for its cure, that the general vigor and
vitality of these cured consumptives were apt to be not
of the best ; that their duration of life was not equal to
the average; and that, even if they escaped a return
of the disease, they were apt to go down before their
normal time under the attack of some other malady.
In short, cure was a poor weapon against the disease
as compared with prevention.

But before this, a careful study of the enemy's po-
sition and investigation of our own resources had
brought another most important and reassuring fact
to light, and that is, that while a distressingly large num-
ber of persons died of tuberculosis, these represented
only a comparatively small percentage of all who had
actually been attacked by the disease. One of the rea-
sons why consumption had corne to be regarded as

TUBERCULOSIS 133

such a deadly disease was that the milder cases of it
were never recognized. It was, and is yet, a common
phrase in the mouths of both the laity and of the medi-
cal profession: "He was seriously threatened with
consumption " ; " She came very near falling into
a decline," — but they recovered. If they did n't die
of it, it wasn't "real" tuberculosis. Now we have
changed all that, and have even begun to go to the op-
posite extreme, of declaring with the German experts,
"Jeder Mann ist am ende ein bischen tuberkulose."
(Every one is some time or another a little bit tuber-
culous.) This sounds appalling at first hearing, but as
a matter of fact it is immensely encouraging. Our first
suspicion of it came from the records of that gruesome,
but pricelessly valuable, treasure-house of solid facts
in pathology — the post-mortem room, the dead-house.
Systematic examinations of all the bodies brought to
autopsy in our great hospitals and elsewhere revealed
at first thirty, then, as the investigation became more
minute and skillful, forty, sixty, seventy-five per cent
of scars in the apices of the lungs, remains of healed cav-
ities, infected glands, or other signs of an invasion by
the tubercle bacillus. Of course, the skeptic challenged
very properly at once : —

" But how do you know that these masses of chalky-
material, these enlarged glands, are the result of tuber-
culosis ? They may be due to some half-dozen other
infections."

Almost before the question was asked a test was
made by the troublesome but convincing method of cut-
ting open these scars, dividing these enlarged glands,

134 PREVENTABLE DISEASES

scraping materials out of their centre, and injecting
them into guinea pigs. Result : from thirty to seventy
per cent of the guinea pigs died of tuberculosis. In
other cases it was not necessary to inoculate, as scrap-
ings or sections from these scar-masses showed tubercle
bacilli, clearly recognizable by their staining reaction.

Here, then, we have indisputable evidence of the
fact that the tubercle bacillus may not only enter some
of the openings of the body, — the nostrils, the mouth,
the lungs, — but may actually form a lodgment and a
growth-colony in the lungs themselves, and yet be
completely defeated by the antitoxic powers of the
blood and other tissues of the body, prevented from
spreading throughout the rest of the lung, most of the
invaders destroyed, and the crippled remnants impris-
oned for life in the interior of a fibroid or chalky mass.

It gave one a distinct shock at the meeting of the
British Medical Association devoted to tuberculosis,
some ten years ago, to hear Sir Clifford Allbutt, one
of the most brilliant and eminent physicians of the
English-speaking world, remark, on opening his
address, " Probably most of us here have had tuber-
culosis and recovered from it."

Here is evidently an asset of greatest and most prac-
tical value, which changes half the face of the field. In-
stead of saving, as best we may, from half to two-thirds
of those who have allowed the disease to get the upper
hand and begin to overrun their entire systems, it
places before us the far more cheering task of building
up and increasing this natural resisting power of the
human body, until not merely seventy per cent of all

TUBERCULOSIS 135

who are attacked by it will throw it off, but eighty,
eighty-five, ninety ! We can plan to stop consumption
by preventing the consumptive. A very small additional
percentage of vigor or of resisting power — such as
could be produced by but a slight improvement in the
abundance of the food-supply, the lighting and venti-
lating of the houses, the length and " fatiguingness " of
the daily toil — might be the straw which would be
sufficient to turn the scale and prevent the tuberculous
individual from becoming consumptive.

Here comes in one of the most important and valu-
able features of our splendid sanatorium campaign
for the cure of tuberculosis, and that is the nature of
the methods employed. If we relied for the cure of the
disease upon some drug, or antitoxin, even though we
might save as many lives, the general reflex or second-
ary effect upon the community might not be in any
way beneficial ; at best it would probably be only nega-
tive. But when the only " drugs " that we use are fresh
air, sunshine, and abundant food, and the only anti-
toxins those which are bred in the patient's own body ;
when, in fact, we are using for the cure of consump-
tion precisely those agencies and influences which will
prevent the well from ever contracting it, then the whole
curative side of the movement becomes of enormous
racial value. The very same measures that we rely
upon for the cure of the sick are those which we would
recommend to the well, in order to make them stronger,
happier, and more vigorous.

If the whole civilized community could be placed
upon a moderate form of the open-air treatment, it

136 PREVENTABLE DISEASES

would be so vastly improved in health, vigor, and effi-
ciency, and saved the expenditure of such enormous
sums upon hospitals, poor relief, and sick benefits, that
it would be well worth all that it would cost, even if
there were no such disease as tuberculosis on earth.

This is coming to be the real goal, the ultimate hope
of the far-sighted leaders in our tuberculosis campaign,
— to use the cure of consumption as a lever to raise to
a higher plane the health, vigor, and happiness of the
entire community.

Enormously valuable as is the open-air sanatorium
as a means of saving thousands of valuable and beloved
lives, its richest promise lies in its function as a school
of education for the living demonstration of methods
by which the health and happiness of the ninety-five
per cent of the community who never will come within
its walls may be built up. Every consumptive cured
in it goes home to be a living example and an enthusi-
astic missionary in the fresh-air campaign. The ulti-
mate aim of the sanatorium will be to turn every farm-
house, every village, every city, into an open-air resort.
When it shall have done this it will have fulfilled its
mission.

Our plan of campaign is growing broader and more
ambitious, but more hopeful, every day. All we have
to do is to keep on fighting and use our brains, and vic-
tory is certain. Our Teutonic fellow soldiers have
already nailed their flag to the mast with the inscrip-
tion : —

"No more tuberculosis after 1930!"

So much for the serried masses of the centre of our

TUBERCULOSIS 137

anti-tuberculosis army, upon which we depend for the
heavy, mass fighting and the great frontal attacks. But
what of the right and the left wings, and the cloud of
skirmishers and cavalry which is continually feeling
the enemy's position and cutting off his outposts ?
Upon the right stretch the intrenchments of the bac-
teriologic brigade, with the complicated but marvel-
ously effective weapons of precision given us by the
discovery of the definite and living cause of the dis-
ease, the Bacillus tuberculosis. Upon the left wing lie
camp after camp of native regiments, whose loyalty
until of very recent years was more than doubtful, —
heredity, acquired immunity, and the so-called im-
provements of modern civilization, steam, electricity,
and their kinsmen.

To the artillerymen of the bacteriologic batteries ap-
pears to have been intrusted the most hopeless task,
the forlorn hope, — the total extermination of a foe so
tiny that he had to be magnified five hundred times
before he was even visible, and of such countless myr-
iads that he was at least a billion times as numerous
as the human race. But here again, as in the centre of
the battle-line, when we once made up our minds to
fight, we were not long in discovering points of attack
and weapons to assault him with.

First, and most fundamental of all, came the consol-
ing discovery that though there could be no consump-
tion without the bacillus, not more than one individual
in seven, of fair or average health, who was exposed
to its attack in the form of a definite infection, suc-
cumbed to it; and that, as strongly suggested by the

138 PREVENTABLE DISEASES

post-mortem findings already described, even those
who developed a serious or fatal form of the disease
had thrown off from five to fifteen previous milder or
slighter infections. So that, to put it roughly, all that
would be necessary practically to neutralize the inju-
riousness of the bacillus would be to prevent about
one-twentieth of the exposures to its invasion which
actually occurred, The other nineteen-twentieths
would take care of themselves. The bacilli are not the
only ones who can be numbered in their billions. If
there are billions of them there are billions of us. We
are not mere units — scarcely even individuals — ex-
cept in a broad and figurative sense. We are confedera-
cies of billions upon billions of little, living animalcules
which we call cells. These cells of ours are no Sun-
day-school class. They are old and tough and cunning
to a degree. They are war-worn veterans, carrying the
scars of a score of victories written all over them. They
are animals; bacteria, bacilli, micrococci, and all their
tribe are vegetables. The daily business, the regular
means of livelihood of the animal cell for fifteen mil-
lions of years past has been eating and digesting the
vegetable. And all that our body-cells need is a little
intelligent encouragement to continue this perform-
ance, even upon disease germs; so that we need n't
be afraid of being stampeded by sudden attack.

The next cheering find was that the worst enemies
of the bacillus were our best friends. Sunlight will kill
them just as certainly as it will give us new life.
The germs of tuberculosis will live for weeks and even
months in dark, damp, unventilated quarters, just pre-

TUBERCULOSIS 139

cisely such surroundings as are provided for them in
the inside bedrooms of our tenements, and the dark,
cellar-like rooms of many a peasant's cottage or farm-
house. In bright sunlight they will perish in from three
to six hours ; in bright daylight in less than half a day.
This is one of the factors that helps to explain the ap-
parent paradox, that the dust collected from the floors
and walls of tents and cottages in which consumptives
were treated was almost entirely free from tuberculous
bacilli, while dust taken from the walls of tenement
houses, the floors of street-cars, the walls of churches
and theatres in New york City, was found to be simply
alive with them. One of the most important elements
in the value of sunlight in the treatment of consump-
tion is its powerful germicidal effect.

CHAPTER VII

TUBERCULOSIS, A SCOTCHED SNAKE
II

/CLOSELY allied to the discovery that sunlight and
\-J fresh air are fatal to the microorganisms of tuber-
culosis came the consoling fact that these bacilli, though
most horribly ubiquitous and apparently infesting both
the heavens above and the earth beneath, had neither
wings nor legs, and were absolutely incapable of pro-
pelling themselves a fraction of an inch. They do not
move — they have to be carried. More than this, like
all other disease-germs, while incredibly tiny and in-
finitesimal, they have a definite weight of their own,
and are subject to the law of gravity. They do not flit
about hither and thither in the atmosphere, thistle-
down fashion, but rapidly fall to the floor of whatever
room or receptacle they may be thrown in. And the
problem of their transference is not that of direct carry-
ing from one victim to the next, but the intermediate
one of infected materials, such as are usually associated
with visible dust or dirt. In short, keep dust or dirt
from the floor, out of our food, away from our fingers
or clothing or anything that can be brought to or near
the mouth, and you will practically have abolished the
possibility of the transference of tuberculosis. The
consumptive himself is not a direct source of danger.

TUBERCULOSIS 141

It is only his filthy or unsanitary surroundings. Put a
consumptive, who is careful of his sputum and cleanly
in his habits, in a well-lighted, well- ventilated room, or,
better still, out of doors, and there will be exceedingly
little danger of any other member of his family or of
those in the house with him contracting the disease.
Wherever there is dirt or dust there is danger, and
there almost only. Thorough and effective house-
reform — not merely in tenements, alas ! but in myr-
iads of private houses as well — would abolish two-
thirds of the spread of tuberculosis.

It is not necessary to isolate every consumptive in
order to stop the spread of the disease. All that is re-
quisite is to prevent the bacilli in his sputum from
reaching the floor or the walls, to have both the latter
well lighted and aired, and, if possible, exposed to direct
sunlight at some time during the day, and to see that
dust from the floor is not raised in clouds by dry sweep-
ing so as to be inhaled into the lungs or settle upon food,
fingers, or clothing, and that children be not allowed
to play upon such floors as may be even possibly con-
taminated. These precautions, combined with the
five-to-one resisting power of the healthy human or-
ganism, will render the risk of transmission of the dis-
ease an exceedingly small one. To what infinitesimal
proportions this risk can be reduced by intelligent and
strict sanitation is illustrated by the fact, already al-
luded to, of the almost complete germ-freeness of the
dust from walls and floors of sanitorium cottages, and
by the even more convincing and conclusive practical
result, that scarcely a single case is on record of the

142 PREVENTABLE DISEASES

transmission of this disease to a nurse, a physician, or
a servant, or other employee in an institution for its
cure.

There is absolutely no rational basis for this panic-
stricken dread of an intelligent, cleanly consumptive, or
for the cruel tendency to make him an outcast and raise
the cry of the leper against him : " Unclean ! Unclean !"

It cannot be too strongly emphasized that consump-
tion is transmitted by way of the floor; and if this relay-
station be kept sterile there is little danger of its trans-
mission by other means.

Practically all that is needed to break this link is the
absolute suppression of what is universally and over-
whelmingly regarded as not merely an unsanitary and
indecent, but a filthy, vulgar, and disgusting habit —
promiscuous expectoration. There is nothing new or
unnatural in this repression, this tabu on expectoration.
In fact, we are already provided with an instinct to
back it. In every race, in every age, in every grade of
civilization, the human saliva has been regarded as the
most disgusting, the most dangerous and repulsive of
substances, and the act of spitting as the last and deep-
est sign of contempt and hatred ; and if directed toward
an individual, the deadliest and most unbearable insult,
which can be wiped out only by blood. Primitive litera-
ture and legend are full of stories of the poisonousness
of human saliva and the deadliness of the human bite.
It was the "bugs" in it that did it. It is most interest-
ing to see how science has finally, thousands of years
afterward, shown the substantial basis of, and gone
far to justify, this instinctive horror and loathing.

TUBERCULOSIS 143

Not merely are the fluids of the human mouth liable
to contain the tubercle bacillus, and that of diphtheria,
of pneumonia, and half a dozen other definite dis-
orders, but they are in perfectly healthy individuals,
especially where the teeth are in poor condition,
simply swarming with millions of bacteria of every
sort, some of them harmless, others capable of setting
up various forms of suppuration and septic inflam-
mation if introduced into a wound, or even if taken
into the stomach. Even if there were no such disease
as tuberculosis a campaign to stamp out promiscuous
expectoration would be well worth all it cost.

Of course, as a counsel of perfection, the ideal pro-
cedure would be promptly to remove each consump-
tive, as soon as discovered, from his house and place
him in a public sanatorium, provided by the state,
for the sajse of removing him from the conditions
which have produced his disease, of placing him under
those conditions which alone can offer a hopeful pros-
pect of cure, and of preventing the further infection
of his surroundings. The only valid objections to such
a plan are those of the expense, which, of course,
would be very great. It would be not merely best,
but kindest, for the consumptive himself, for his im-
mediate family, and for the community. And enor-
mous as the expense would be, when we have become
properly aroused and awake to the huge and almost
incredible burden which this disease, with its one
hundred and fifty thousand deaths a year, is now
imposing upon the United States, — five times as
great as that of war or standing army in the most mili-

144 PREVENTABLE DISEASES

tary-mad state in Christendom, — the community
will ultimately assume this expense. So long, however,
as our motto inclines to remain, "Millions for cure,
but not one cent for prevention," we shall dodge this
issue.

There can be no question but that each state and
each municipality of more than ten thousand inhab-
itants ought to provide an open-air camp or colony of
sufficient capacity to receive all those who are willing
to take the cure but unable to meet the expense of a
private institution; and, also, some institution of
adequate size, to which could be sent, by process of
law, all those consumptives who, either through per-
versity, or the weakness and wretchedness due to their
disease, or the apathy of approaching dissolution,
fail or are unable to take proper precautions.

When we remember that the careful investigations
of the various dispensaries for the treatment of tuber-
culosis in our larger cities, New York, Boston, Cleve-
land, report that on an average twenty to thirty per
cent of all children living in the same room or apart-
ment with a consumptive member of their family are
found to show some form of tuberculosis, it will be
seen how well worth while, from every point of view,
this provision for the removal and sanatorium treat-
ment of the poorer class of these unfortunates would
be. These dispensaries now have, as a most important
part of their campaign against the disease, one or
more visiting nurses, who, whenever a patient with
tuberculosis is brought into the dispensary, visit him
in his home, show him how to ventilate and light

TUBERCULOSIS 145

his rooms as well as may be, give practical demon-
strations of the methods of preventing the spread of
the disease, advise him as to his food, and see that
he is supplied with adequate amounts of milk and eggs,
and, finally, round up all the children of the family
and any adults who are in a suspicious condition of
health, and bring them to the dispensary for exami-
nation. Distressing as are these findings, reaching
in some cases as high as fifty and sixty per cent of
the children, they have already saved hundreds of
children, and prevented hundreds of others from
growing up crippled or handicapped.

It must be remembered that the tubercle bacillus
causes not merely disease of the lungs in children but
also a large majority of the crippling diseases of the
bones, joints, and spine, together with the whole group
of strumous or scrofulous disorders, and a large group
of intestinal diseases and of brain lesions, resulting
in convulsions, paralysis, hydrocephalus, and death.
The battle-ground of the future against tuberculosis
is the home.

We speak of the churchyard as "haunted," and we
recoil in horror from the leper-house or the cholera-
camp. Yet the deadliest known hotbed of horrors,
the spawning ground of more deaths than cholera,
smallpox, yellow fever, and the bubonic plague com-
bined, is the dirty floor of the dark, unventilated
living-room, whether in city tenement or village
cottage, where children crawl and their elders spit.

It is scarcely to the credit of our species that for
convincing, actual demonstrations of what can be

146 PREVENTABLE DISEASES

done toward stamping out tuberculosis, by measures
directed against the bacillus alone, we are obliged to
turn to the lower animals. By a humiliating paradox
we are never quite able to put ourselves under those
conditions which we know to be ideal from a sanitary
point of view. There are too many prejudices, too
many vested interests, too many considerations of
expense to be reckoned with. But with the lower
animals that come under our care we have a clear
field, free from obstruction by either our own preju-
dices or those of others. In this realm the stamping
out of tuberculosis is not merely a rosy dream of the
future but an accomplished fact, in some quarters
even an old story. Two illustrations will suffice, one
among domestic animals, the other among wild ani-
mals in captivity. The first is among pure-bred dairy
cattle, the pedigreed Jerseys and Holsteins. No sooner
did the discovery of the bacillus provide us with a
means of identification, than the well-known " perl-
sucht" of the Germans, or "grapes" of the English
veterinarians — both names being derived from the
curious rounded masses or nodules of exudate found
in the pleural cavity and the peritoneum (around the
lungs and the bowels), and supposed to resemble
pearls and grapes respectively — were identified as<
tuberculosis, and cows were found very widely infected
with it. This unfortunately still remains the case with
the large mass of dairy cattle. But certain of the more
intelligent breeders owning valuable cattle proceeded
to take steps to protect them.

The first step was to test their cows with tuberculin*

TUBERCULOSIS 147

promptly weeding out and isolating all those that re-
acted to the disease. It was at first thought necessary to
slaughter all these at once. But it was later found that,
if they were completely isolated and prevented from
communicating the disease to others, this extreme mea-
sure was necessary only with those extensively diseased.
The others could be kept alive, and if their calves were
promptly removed as soon as born, and fed only upon
sterilized or perfectly healthy milk, they would be free
from the disease. And thus the breeding-life of a par-
ticularly valuable and high-bred animal might be pro-
longed for a number jpi years. They must, however,
be kept in separate buildings and fields, and preferably
upon a separate farm from the rest of the herd.

Those cows found healthy were given the best of
care, including a marked diminution of the amount of
housing or confinement in barns, and were again tested
at intervals of six months, several times, to weed out
any others which might still have the infection in their
systems. In a short time all signs of the disease disap-
peared, and no other cases developed in these herds
unless fresh infection was introduced from without.
To guard against this, each farm established a quaran-
tine station, where all new-bought animals, after having
been tested with tuberculin and shown to be free from
reaction, are kept for a period of at least a year, for
careful observation and study, before being allowed
to mix with the rest of the herd. It is now a common
requirement among intelligent breeders of pedigreed
cattle to demand, as a formal condition of sale, their
submission to the tuberculin test, or the certificate of

148 PREVENTABLE DISEASES

a competent veterinarian that the animal has been so
tested without reacting. Protected herds have now been
in existence under these conditions, notably in Den-
mark, where the method was first reduced to a system
under the able leadership of Professor Bang, of Copen-
hagen, for ten years with scarcely a single case of tuber-
culosis developing. Only a fraction of one per cent of
calves from the most diseased mothers are born diseased.

Not only is the method spreading rapidly among
the more intelligent class of breeders, but many pro-
gressive countries of Europe and states of our Union
require the passing of the tuberculin test as a requisite
to the admission within their borders of cattle intended
for breeding purposes. So that, while the problem is
still an enormous one, it is now confidently believed
that complete eradication of bovine tuberculosis is only
a question of time.

The other instance furnishes a much more crucial
test, as it is carried out upon wild animals under the
unfavorable conditions of captivity in a strange climate,
like our slum-dwellers from sunny Italy, and comes
home to us more closely in many respects, inasmuch
as it is concerned with our nearest animal relatives
on the biological side — monkeys and apes, in zoologi-
cal gardens.

Tuberculosis is a perfectly frightful scourge to these
unfortunate captives, causing not infrequently thirty,
fifty, and even sixty per cent of the deaths. This, how-
ever, is only in keeping with their frightful general mor-
tality. The collection of monkeys in the London Zoo,
for instance, some fifteen years ago, was absolutely

TUBERCULOSIS 149

exterminated by disease and started over afresh every
three years, a death-rate of thirty-five per cent per an-
num as compared with our human rate of about two
per cent per annum. Here, it would seem, was an in-
stance where there was little need to call in the bacillus.
Brought from a tropical climate to one of raw, damp
fog and smoke, from the freedom of the air-roads
through the tree-tops to the confinement of dismal and
often dirty cages in a stuffy, overheated house, con-
demned to a diet which at best could be but a feeble
and far-distant imitation of their natural food, it
seemed little wonder j;hat they " jes' natcherly pined
away an' died."

But let the results speak. A thorough system of quar-
antine was enforced, beginning with one of the Vienna
gardens, and finally reaching one of its most brilliant
and successful exemplifications in our own New York
Zoological Gardens in the Bronx. All animals pur-
chased or donated were tested with tuberculin, and
those that reacted were either painlessly destroyed or
disposed of. Those which appeared to be immune were
kept in a thoroughly healthy, sanitary quarantine sta-
tion for six months or a year, and again tested by tuber-
culin before being introduced into the cages. The origi-
nal stock of monkeys was treated in the same manner
or else destroyed completely, and the houses and cages
thoroughly cleaned and sterilized or new ones con-
structed. Keepers employed in the monkey-house were
carefully tested for signs of tuberculosis, and rejected
or excluded if any appeared. Signs were posted for-
bidding any expectoration or feeding of the animals

150 PREVENTABLE DISEASES

(which latter is often done with nuts or fruit which had
been cracked or bitten before being handed to the
monkeys) by the general public, and these rules were
strictly enforced.

At the same time the houses were thoroughly ven-
tilated and exposed to sunlight as much as possible, and
the animals were turned out into open air cages when-
ever the weather would possibly permit. As a result the
mortality from tuberculosis promptly sank from thirty
per cent to five or six per cent. In our Bronx Zoo, for
instance, it has become decidedly rare as a cause of
death in monkeys, no case having occurred in the mon-
key-house for eighteen months past. What is even
more gratifying, the general mortality declined also,
though in less proportion, so that, instead of losing
twenty-five to thirty per cent of the animals in the
house every year, a mortality of ten to fifteen per cent
is now considered large.

And to think that we might achieve the same results
in our own species if we would only treat ourselves as
well as we do our monkey captives ! To " make a mon-
key of one's self" might have its advantages from a
sanitary point of view.

" But this method," some one will remind us, " would
silence only a part of the enemy's infection batteries."
Even supposing that we could prevent the spread of the
disease from human sources, what of the animal con-
sumptives and their deadly bacilli ? If the milk that we
drink, and the beef, pork, and poultry that we eat, are
liable to convey the infection, what hope have we of
ever stopping the invasion ?

TUBERCULOSIS 151

The question is a serious one. But here again a thor-
ough and careful study of the enemy's position has
shown the danger to be far less than it appeared at first
sight. Even bacilli have what the French call " the de-
fects of their virtues." Their astonishing and most dis-
quieting powers of adjustment, of accommodation to
the surroundings in which they find themselves, namely,
the tissues and body-fluids of some particular host
whom they attack, bring certain limitations with them.
Just in so far as they have adjusted themselves to live
in and overcome the opposition of the body-tissues of a
certain species of animals, just to that degree they have
incapacitated themselves to live in the tissues of any other
species.

Some of the most interesting and far-reachingly im-
portant work that has been done in the bacteriology of
tuberculosis of late years has concerned itself with the
changes that have taken place in different varieties and
strains of tubercle bacilli as the result of adjusting them-
selves to particular environments. The subject is so
enormous that only the crudest outlines can be given
here, and so new that it is impossible to announce any
positive conclusions. But these appear to be the domi-
nant tendencies of thought in the field so far.

Though nearly all domestic animals and birds, and
a majority of wild animals under captivity, are sub-
ject to the attack of tuberculosis, practically all the
infections hitherto studied are caused by one of three
great varieties or species of the tubercle bacillus : the
human, infesting our own species ; the bovine, attacking
cattle; and the avian, inhabiting the tissues of birds,

152 PREVENTABLE DISEASES

especially the domestic fowl. These three varieties or
species so closely resemble one another that they were
at one time regarded as identical, and we can well re-
member the wave of dismay which swept over the
medical world when Robert Koch announced that the
" perlsucht " of cattle was a genuine and unquestioned
tuberculosis due to an unmistakable tubercle bacillus.
But as these varieties were thoroughly and carefully
studied, it was soon found that they presented definite
marks of differentiation, until now they are universally
admitted to be distinct varieties, each with its own life
peculiarities, and, according to some authorities, even
distinct species.

"But," we fancy we hear some one inquire impa-
tiently, " what do those academic, technical distinctions
matter to us ? Whether the avian tuberculosis germ is
a variety or a true species may be left to the taxono-
mists, but it is of no earthly importance to us."

On the contrary, it is of the greatest importance. For
the distinctive feature about a particular species of
parasite is that it will live and flourish where another
species will die, and, vice versa, will die in surround-
ings where its sister species might live and thrive.

One of the first differences found to exist among
these three types of bacteria was the extraordinary
variation in their power of attacking different animals.
For instance, while the guinea-pig and the rabbit could
be readily inoculated with human bacilli, they could
only be infected with difficulty by cultures of the bovine
bacillus ; while the only animal that could be inoculated
at all with the avian or bird bacillus was the rabbit,

TUBERCULOSIS 153

and he only occasionally. In fact, bacteriologists soon
came to the consoling conclusion that the avian bacillus
might be practically disregarded as a source of danger
to human beings, so widely different were the condi-
tions in their moist and moderately warm tissues to
those of the dry and superheated tissues of the bird
to which it had adjusted itself for so many generations.

And next came the bold pronunciamento of no less
an authority than Koch himself, that the bovine bacil-
lus also was so feebly infective to human beings that it
might be practically disregarded as a source of danger.
This promptly split tjae bacteriologists of the world
into two opposing camps, and started a warfare which
is still being waged with great vigor. As the question
is still under hot dispute by even the highest authorities,
it is, of course, impossible to pronounce any definite con-
clusions. But the net result to date appears to be that
while Koch made a serious error of judgment in de-
claring that meat and milk as a source of danger to
human beings of tuberculosis might be disregarded,
yetffor practical purposes, his position is, in the main,
correct : the actual danger from the bovine bacillus to
human beings is relatively small.

There was nothing whatever improbable, in the first
place, in the correctness of Koch's position.

It is one of the few consoling facts, well known to all
students of comparative pathology or the diseases of
the different species of animals, how peculiarly special-
ized they are in the choice of their diseases, or, per-
haps, to put it more accurately, how particular and re-
stricted disease-germs are in their choice of a host. For

154 PREVENTABLE DISEASES

instance, out of twenty-eight actually infectious diseases
which are most common among the domestic animals
and man, other than tuberculosis, only one — rabies

— is readily communicable to more than three species ;
only three — anthrax, tetanus, and foot-and-mouth
disease — are communicable to two species ; while the
remainder are almost absolutely confined to one species,
even though this be thrown into closest contact with
half a dozen others.

Again, we have half a dozen similar instances in the
case of tuberculosis itself. The horse and the sheep,
for instance, are both most intimately associated with
cattle, pastured in the same fields, fed upon the same
food, and yet tuberculosis is almost unknown in sheep
and decidedly uncommon in horses, and when it does
occur in them is from a human source. The goat is
almost equally immune from both human and bovine
forms, while the cat and the dog, although developing
the infection with a low degree of frequency, almost
invariably trace that infection to a human source.

There is, therefore, no a priori reason whatever why
we should be any more susceptible to bovine tubercu-
losis than the remainder of the domestic animals. It is
only fair to say, however, that the animal whose diet

— and appetite — most closely resembles ours, the hog,
is quite fairly susceptible to bovine tuberculosis if fed
upon the milk or meat of tuberculous cattle.

Next came the particularly consoling fact that al-
though nothing has been more striking than the great
increase in the amounts of meat and milk consumed by
the mass of the community during our last twenty-

TUBERCULOSIS 155

»

years' progress in civilization, this has been accompa-
nied not by any increase of tuberculosis, but by a dimi-
nution of from thirty-five to forty-five per cent. The
allegation so frequently made that there has been an
increase in the amount of infantile tuberculosis has
been shown, upon careful investigation by Shennan of
Edinburgh, Guthrie of London, Kossel in Germany,
Comby in France, Bovaird in New York, and others,
to be practically without foundation.

Then, while repetitions of Koch's experiment, upon
which his announcement was based, of inoculating
calves and young cattle ^vith human bacilli have proved
that a certain number of them can be, under appropriate
circumstances, made to develop tuberculosis, that nunv
ber has never been a large percentage of the animals
tested, and in many cases the infection has been a local
one, or of a mild type, which has resulted in recovery.
Lastly, while a number of bacilli, with bovine culture
and other characteristics, have been recovered from
the bodies of children dying of tuberculosis, and these
bacilli have proved virulent to calves when injected
into them, yet, as a matter of historical fact, the actual
number of instances in which children or other human
beings have been definitely proved to have contracted
the disease from the milk of a tuberculous cow is still
exceedingly and encouragingly small. A careful study
of the entire literature of the past twenty years, some
three years ago, revealed only thirty-seven cases ; and of
these thirty-seven Koch's careful investigations have
since disproved the validity of nine. ^

On the other hand, it is anything but safe to accept

156 PREVENTABLE DISEASES

Koch's practical dictum and neglect the meat and
milk of cattle as a source of danger in tuberculosis.
First, because the degree of our immunity against the
bovine bacilli is still far from settled ; and, second, be-
cause, while bacteriologists are fairly agreed that the
avian, the bovine, and the human represent three dis-
tinct and different variations, if not species, of the bacil-
lus, they are almost equally agreed that they are prob-
ably the descendants of one common species, which
may possibly be a bacillus commonly found upon
meadow grasses, particularly the well-known timothy,
and hence very frequently in the excreta of cattle, and
known as the grass bacillus or dung bacillus of Mceller.
This bacillus has all the staining, morphological, and
even growth characteristics of the tubercle bacillus ex-
cept that it produces only local irritation and little nod-
ular masses, if injected into animals. Our knowledge
of its existence is, however, of great practical import-
ance, inasmuch as it warned us that in our earlier
studies of the bacilli contained in milk and butter we
have been mistaking this organism for a genuine tuber-
cle bacillus. As a consequence, of late years our tests
for the presence of tubercle bacilli in milk are made not
only by searching for the organism with the microscope,
but also by injecting the centrifugated sediment of the
infected milk into guinea pigs, to see if it proves infec-
tious. Many of our earlier statements as to the pre-
sence of tubercle bacilli in milk and butter are now
invalidated on this account.

Not only are the three varieties of tubercle bacilli
probably of common origin, but they may, under cer-

TUBERCULOSIS 157

tain peculiar conditions, be transformed into one an-
other, or, at least, enabled to live under the conditions
favorable to one another. This was shown nearly fif-
teen years ago by the ingenious experiments of Nocard,
the great veterinary pathologist. He took a culture of
bovine bacilli, which were entirely harmless to fowls,
and, inclosing them in a collodion capsule, inserted
them into the peritoneal cavity of a hen. The collodion
capsule permitted the fluids of the body to enter and
provide food for the bacilli, but prevented the admis-
sion of the leucocytes to attack and destroy them.
After several weeks the capsule was removed, the ba-
cilli found still alive, and transferred to another capsule
in another fowl. When this process had been repeated
some five or six times, the last generation of bacilli was
injected into another fowl, which promptly developed
tuberculosis, showing that by gradually exposing the
bacilli for successive generations to the high tempera-
ture of the bird's body (from five to fifteen degrees
above that of the mammal), they had become accli-
mated, as it were, and capable of developing. So that
it is certainly quite conceivable that bovine bacilli
introduced in milk or meat might manage to find a
haven of refuge or lodgment in some out-of-the-way
gland or tissue of the human body, and there avoid
destruction for a sufficiently long time to become ac-
climated and later infect the entire system.

This is the method which several leaders in bacteri-
ology, including Behring (of antitoxin fame), believe
to be the principal source and method of infection of
the human species. The large majority, however, of

158 PREVENTABLE DISEASES

bacteriologists and clinicians are of the opinion that
ninety per cent of all cases of human tuberculosis are
contracted from some human source. So that, while
we should on no account slacken our fight against tu-
berculosis in either cattle or birds, and should encour-
age in every way veterinarians and breeders to aim for
its total destruction, — a consummation which would
be well worth all it would cost them, purely upon eco-
nomic grounds, just as the extermination of human
tuberculosis would be to the human race, — yet we
need not bear the burden of feeling that the odds
against us in the fight for the salvation of our own
species are so enormous as they would be, had we no
natural protection against infection from animals and
birds.

The more carefully we study all causes of tubercu-
losis in children, the larger and larger percentage of
them do we find to be clearly traceable to infection
from some member of the family or household. In
Berlin, for instance, Kayserling reports that seventy
per cent of all cases discovered can be traced to direct
infection from some previous human case.

Lastly, what of the left wing of our army of extermi-
nation, composed of those light-horse auxiliaries — the
general progress and new developments of civilization,
and the net results upon the individual of the experi-
ences of his ancestors, which we designate by the term
"heredity" ? For many years we were in serious doubt
how far we could depend upon the loyalty of this group
of auxiliaries, and many of the faint-hearted among us
were inclined to regard their sympathies as really

TUBERCULOSIS 159

against us rather than with us, and prepared to see
them desert to the enemy at any time. It was pointed
out, as of great apparent weight, that consumption was
decidedly and emphatically a disease of civilization;
that it was born of the tendency of men to gather them-
selves into clans and nations and crowd themselves
into villages and those hives of industry called cities ;
that the percentage of deaths from tuberculosis in any
community of a nation or any ward of a city was high in
direct proportion to the density of its population ; and
that the whole tendency of civilization was to increase
this concentration, this congestion of ground space,
this piling of room upon room, of story upon story.
How could we possibly, in reason, expect that the influ-
ences which had caused the disease could help us to
cure it?

But the improbable has already happened. Never
has there been a more rapid and extraordinary growth
of our great cities as contrasted with our rural districts,
never has there been a greater concentration of popula-
tion in restricted areas than during the past thirty-five
years. And yet, the prevalence of tuberculosis in that
time, in all civilized countries of the earth, has shown
not only no increase, but a decrease of from thirty-Jive
to fifty per cent. To-day the world power which has the
largest percentage of its inhabitants gathered within
the limits of its great cities, England, has the lowest
death-rate in the civilized world from tuberculosis, al-
though closely pressed within the last few years by the
United States, whose percentage of urban population
is almost equally large, while England's sister island,

160 PREVENTABLE DISEASES

Ireland, with one of the highest percentages of rural
and the lowest of urban population, has one of the
highest death-rates from tuberculosis, and one which
is, unfortunately, increasing.

The real cure for the evils of civilization would ap-
pear to be more civilization, or, better, perhaps, higher
civilization. Nor are these exceptional instances. Take
practically any city, state, or province in the civilized
world, which has had an adequate system of recording
all births and deaths for more than thirty years, and
you will find a decrease in the percentage of deaths
from tuberculosis in that time of from twenty to forty
per cent. The city of New York's death-roll, for in-
stance, from tuberculosis, per one thousand living, is
some thirty-five per cent less than it was thirty years
ago. So that our fight against the disease is beginning
to bear fruit already. As Osier puts it, we run barely
half the risk of dying of tuberculosis that our parents
did and barely one-fourth of that of our grandparents.

But this gratifying improvement goes deeper, and is
even more significant than this. It is, of course, only
natural to expect that our vigorous fight against the
spread of the infection of the disease would give us
definite results. But the interesting feature of the situa-
tion is that this diminution in England and in Germany,
for instance, began not merely twenty, but thirty, forty,
even fifty years ago — two decades before we even
knew that tuberculosis was an infectious disease with
a contagion that could be fought.

In the case of England, for instance, we have the,
at first sight, anomalous and even improbable fact that

TUBERCULOSIS 161

the rate of decline in the death-rate from tuberculosis
for the twenty years preceding the discovery of Koch's
bacillus was almost as great as it has been in the twenty
years since. In other words, the general tendency, born
of civilization, toward sanitary reform, better housing,
better drainage, higher wages and consequently more
abundant food, rigid inspection of food materials, fac-
tory laws, etc., is of itself fighting against and diminish-
ing the prevalence of the "great white plague" by im-
proving the resisting power and building up the health
of the individual. Civilization is curing its own ills.

It must be remembered that vital statistics, showing
the decrease of a given disease within the past forty or
fifty years, probably represent not merely a real de-
crease of the amount indicated by the figures but an
even greater one in fact ; because each succeeding dec-
ade, as our knowledge of disease and the perfection of
our statistical machinery improves and increases, is
sure to show a prompter recognition and a more thor-
ough and complete reporting of all cases of the disease
occurring. Statistics, for instance, showing a moderate
apparent rate of increase of a disease within the last
thirty years are looked upon by statisticians as really
indicating that it is at a standstill. It is almost certain
that at least from ten to twenty per cent more of the
cases actually occurring will be recognized during life
and reported after death than was possible with our
more limited knowledge and less effective methods of
registration thirty years ago. So we need not hesitate to
encourage ourselves to renewed effort by the reflection
that we are enlisted in a winning campaign, one in

162 PREVENTABLE DISEASES

which the battle-line is already making steady and even
rapid progress, and which can have only one termina-
tion so long as we retain our courage and our common-
sense.

This decline of the tuberculosis death-rate is, of
course, only a part of the general improvement of phy-
sique which is taking place under civilization. If we
could only get out from under the influence of the
"good old times" obsession and open our eyes to see
what is going on about us ! There is nothing mysteri-
ous about it. The soundest of physical grounds for
improving health can be seen on every hand. We point
with horror, and rightly, to the slum tenement house,
but forget that it is a more sanitary human habita-
tion than even the houses of the nobility in the Eliza-
bethan age. We become almost hysterical over the
prospect that the very fibre of the race is to be rotted by
the adulteration of our food-supply, by oleomargarine
in the butter, by boric acid in our canned meats, by
glucose in our sugar, and aniline dyes in our candies,
but forget that all these things represent extravagant
luxuries unheard of upon the tables of any but the
nobility until within the past two hundred, and in
some cases, one hundred, years. Up to three hundred
years ago even the most highly civilized countries of
Europe were subject to periodic attacks of famine;
our armies and navies were swept and decimated with
scurvy, from bad and rotten food-supplies; almost
every winter saw epidemics breaking out from the
use of half-putrid salted and cured foods ; only forty
years ago, a careful investigation of one of our most

TUBERCULOSIS 163

conservative sociologists led him to the conclusion
that in Great Britain thirty per cent of the population
never in all their lives had quite as much as they could
eat, and for five months out of the year were never
comfortably warm. The invention of steam, with its
swift and cheap transportation of food-supplies, put-
ting every part of the earth under tribute for our tables,
meat every day instead of once a week for the work-
ingman, and the introduction of sugar in cheap and
abundant form, with the development of the dietary
in fruits and cereals which this has made possible, have
done more to improve the resisting power and build
up the physique of the mass of the population in our
civilized communities, than ten centuries of congestion
and nerve-worry could do 'to break it down.

We shake our heads, and prate fatuously that " there
were giants in those days," ignorant of the thoroughly
attested fact, that the average stature of the European
races has increased some four inches since the days
of the Crusaders, as shown by the fact that the common
British soldier of to-day — Mr. Kipling'-s renowned
"Tommy Atkins," who is looked upon by the classes
above him in the social scale as a short, undersized
sort of person — can neither fit his chest and shoulders
into their armor, get his hands comfortably on the hilts
of their famous two-handed swords, nor even lie down
in their coffins.

We are at last coming to acknowledge with our lips,
although we scarcely dare yet to believe it in our heart
of hearts, that not merely the death-rate from tuber-
culosis, but the general death-rate from all causes in

164 PREVENTABLE DISEASES

civilized communities, is steadily and constantly de-
clining ; that the average longevity has increased nearly
ten years within the memory of most of us, chiefly by
the enormous reduction in the mortality from infant
diseases ; and that, though the number of individuals
in the community who attain a great or notable age is
possibly not increasing, the percentage of those who
live out their full, active life, play their man's or wo-
man's part in the world, and leave a group of properly
fed, vigorous, well-trained, and educated children be-
hind them to carry on the work of the race, is far
greater than ever before. Even in our much-denounced
industrial conditions, made possible by the discovery of
steam with its machinery and transportation, the gain
has far exceeded the loss. While machinery has made
the laborer's task more monotonous and more confin-
ing, the net result has been that it has shortened his
hours and increased his efficiency.

Even more important, it has increased his intelli-
gence by demanding and furnishing a premium for
higher degrees of it. Naturally, one of the first uses
which he has made of his increased intelligence has
been to demand better wages and to combine for the
enforcement of his demands. The premium placed
upon intelligence has led both the broader-minded,
more progressive, and more humane among employers,
and the more intelligent among employees, to recog-
nize the commercial value of health, and of sanitary
surroundings, comfort, and healthy recreations, as a
means of promoting this. The combined results of
these forces are seen in the incontestable, living fact

TUBERCULOSIS 165

that the death-rate from tuberculosis among intelligent
artisans and in well-regulated factory suburbs is al-
ready below that of many classes of outdoor and even
farm laborers, whose day is from twelve to fourteen
hours, and whose children are worked, and often over-
worked, from the time that they can fairly walk alone,
with as disastrous and stunting results as can be found
in any mine or factory. Child-labor is one of the oldest
of our racial evils, instead of, as we often imagine, the
newest.

All over the civilized world to-day the average gen-
eral death-rate of each city, slums included, is now be-
low that of many rural districts in the same country.
If I were to be asked to name the one factor which had
done more than any other to check the spread and
diminish the death-rate from tuberculosis I should un-
hesitatingly say, the marked increase of wages among
the great producing masses of the country, with the con-
sequent increased abundance of food, better houses,
better sanitary surroundings, and last, but not least,
shorter hours of labor.

Underfeeding and overwork are responsible for more
deaths from tuberculosis than any other ten factors. Rest
and abundant feeding are the only known means for
its cure.

This is one of the reasons why the medical profes-
sion has abandoned all thought of endeavoring to fight
the disease single-handed, and is striving and straining
every nerve to enlist the whole community in the fight.
Its burden rests, not upon the unfortunate individual
who has become tuberculous, but upon the community

166 PREVENTABLE DISEASES

which, by its ignorance, its selfishness, and its greed,
has done much to make him so. What civilization has
caused it is under the most solemn obligation to cure.

One more brigade of irregular troops on the ex-
treme left remains to be briefly reviewed, and that is
those forces resulting from the successive exposure of
generations to the physical influences of civilization,
including the infectious diseases. For years we never
dreamed of even attempting to raise any levies among
these border tribes of more than doubtful loyalty.
Indeed, they were supposed to be our open enemies.

When we first attempted to take a world-view of
tuberculosis, the first great fact that stood out plainly
was that it was emphatically a disease of the walled
town and the city ; that the savage and the nomad bar-
barian were practically free from it ; that range cattle
and barnyard fowls seldom fell victims to it, while their
housed and confined cousins in the dairy barn and the
breeding-pens suffered frightfully. It was one of our
commonplace sayings that we must " get back to na-
ture," get away from the walled city into the open
country, revert from the conditions of civilization in -a
considerable degree to those of barbarism, in order to
escape. While, as for heredity, its influence was al-
most dead against us. How could a race be exposed
to a disease like tuberculosis, generation after genera-
tion, without having its vital resistance impaired ?

But a marked and cheering change has come over
our attitude to this wing of the battle of life. So far
from regarding it as in any sense necessary to revert

TUBERCULOSIS 167

to barbarism, still less to savagery, for either the pre-
vention or the cure of disease, we have discovered by
the most convincing, practical experience, that we
can, in the first place, with the assistance of the loco-
motive and trolley, combined with modern building
skill and sanitary knowledge, put even our city-dwellers
under conditions, in both home and workshop, which
will render them far less likely to contract tubercu-
losis than if they were in a peasant's cottage or the
average farmhouse or merchant's house of a hundred
years ago, to say nothing of the cave, the dugout, or
the hut of the savage.

In the second place, instead of simply "going back
to nature " and living in brush-shelters on what we
can catch or shoot, it takes all the resources of civiliza-
tion to place our open-air patients in the ideal condi-
tions for their recovery. Let any consumptive be reck-
less enough to "go back to nature," unencircled by
the strong arm of civilized intelligence and power, and
unprotected by her sanitary shield, and nature will
kill him three times out of five. There could not be
a more dangerous delusion than the all-too-common
one — that all that is necessary for the cure of con-
sumption is to turn the victim loose among the elements,
even in the mildest and most favorable of climates.

He must be fed upon the most abundant and nu-
tritious of foods, even the simplest being milk of a
richness which is given by no kind of wild cattle, and
which, indeed, only the most carefully bred and highly
civilized strains of domestic cattle are capable of pro-
ducing ; eggs such as are laid by no wild bird or by

168 PREVENTABLE DISEASES

any but the most highly specialized of domestic poul-
try at the season of the year when they are most re-
quired ; steaks and chops, hams and sides of bacon,
sugar and fruits and nuts, which simply are not pro-
duced anywhere outside of civilization, and often only
in the most intelligent and progressive sections of
civilized communities.

Put him upon even the average diet of many people
in this progressive and highly civilized United States
the year round, — with its thin milk, its pulpy, half-
sour butter, its tough meat, its half-rancid pickled
pork, its short three months of really fresh vegetables
and good fruit, and six months of eternal cabbage, po-
tatoes, dried apples, and prunes, — and he will fail to
build up the vigor necessary to fight the disease, even
in the purest and best of air.

The saddest and most pitiful tragedies which the
consumptive health-resort physician can relate are
those of wretched sufferers, — even in a comparatively
early stage of the disease, — whose misguided but
well-meaning friends have raised money enough to
pay their fare out to Colorado, California, Arizona, or
New Mexico, and expect them to get work on a ranch,
so as to earn their living and take the open-air treat-
ment at the same time.

Three things are absolutely necessary for a reason-
able prospect of cure of consumption. One is, abun-
dance of fresh air, day and night. Another, abundance
of the best quality of food. And the third, absolute —
indeed, enforced — rest during the period of fever.
Let any one of these be lacking, and your patient will

TUBERCULOSIS 169

die just as certainly as if all three were. Not one in five
of those who go out to climates with even a high repu-
tation as health-resorts — expecting to earn their own
living or to "rough it" in shacks or tents on three or
four dollars a week, doing their own cooking and
taking care of themselves — recovers. They have a
four- to-one chance of recovery in any climate in which
they can obtain these three simple requisites, and a
four-to-one chance of dying in any climate in which
any one of these is lacking.

Instead of nature being able to cure the consump-
tive unaided, as a matter of fact she has neither the
ability nor the inclination to do anything of the sort.
There is no class of patients whose recovery depends
more absolutely upon a most careful and intelligent
study and regulation of their diet, of every detail of
their life throughout the entire twenty-four hours, and
of the most careful adjustment of air, food, heat, cold,
clothing, exercise, recreation, by the combined forces
of sanitarian, nurse, and physician. So that, instead of
feeling that only by reverting to savagery can consump-
tion be prevented, we have no hesitation in saying that
it is only under civilization, and civilization of the highest
type, that we have any reasonable prospect of cure.

Finally, we are getting over our misgivings as to the
intentions of the hereditary brigade. It is certainly not
our enemy, and may probably turn out to be one of our
best friends.

Our first sidelight on this question came in rather a
surprising manner. It was taken for granted, almost
as axiomatic, that if the conditions of savage life were

170 PREVENTABLE DISEASES

such as to discourage, if not prevent, tuberculosis,
certainly, then, the race which had been exposed to
these conditions for countless generations would have
a high degree of resisting power to the disease. But
what an awakening was in store for us ! No sooner did
the army surgeon and medical missionary settle down
in the wake of that extraordinary world-movement of
Teutonic unrest, which has resulted in the colonization
of half the globe within the past two or three hundred
years, than it was discovered that, although the hunt-
ing or nomad savage had not developed tuberculosis,
and the disease was emphatically born of civilization,
yet the moment that these healthy and vigorous chil-
dren of nature were exposed to its infection, instead of
showing the high degree of resisting power that might
be expected, they died before it like sheep.

From all over the world — from the Indians of our
Western plains, the negroes of our Southern States, the
islanders of Polynesia, New Zealand, Hawaii, Samoa
— came reports of tribes practically wiped out of exist-
ence by the "White Plague" of civilization. To-day
the death-rate from tuberculosis among our Indian
wards is from three to six times that of the surrounding
white populations. The negro population of the South-
ern States has nearly three times the death-rate of the
white populations of the same states. Instead of cen-
turies of civilization having made us more susceptible
to the disease than those savages who probably most
nearly parallel our ancestral conditions of a thousand
to fifteen hundred years ago, we seem to have ac-
quired irom three to five times their resisting power

TUBERCULOSIS 171

against it. Not only this, but those races among us
which have been continuous city-dwellers for a score
of generations past have acquired a still higher degree
of immunity.

In every civilized land the percentage of deaths from
tuberculosis among the Jews, who, from racial and reli-
gious prejudices, have been prisoners of the Ghetto foi
centuries, is about half to one-third that of their Ge^
tile neighbors. In certain blocks of the congested dis-
tricts of New York and Chicago, for instance, the Jew-
ish population shows a death-rate of only one hundred
and sixty-three per hundred thousand living, while
the Gentile inhabitants of similar blocks show the
appalling rate of five hundred and sixty-five. Similarly,
by a strange apparent paradox, the highest mortality
from tuberculosis in the United States is not in those
states having the greatest urban population, but, on
the contrary, in those having the largest rural popula-
tion.

The ten highest state tuberculosis death-rates con-
tain the names of Tennessee, Kentucky, West Virginia,
Virginia, and South Carolina, while New York, Penn-
sylvania, and Massachusetts are among the lowest.

The subject is far too wide and complicated to admit
of any detailed discussion here. But, explain it as we
may, the consoling fact remains that civilized races,
including slum-dwellers, have a distinctly lower death-
rate from tuberculosis than have savage tribes which
are exposed to it even under most favorable climatic
and hygienic conditions; that those races which have
survived longest in city and even slum surroundings

172 PREVENTABLE DISEASES

have a lower death-rate than the rest of the community
under those conditions ; and that certain of our urban
populations have lower death-rates than many of our
rural ones.

As for the immediate effect of heredity in the produc-
tion of the disease, the general consensus of opinion
among thoughtful physicians and sanitarians now is
that direct infection is at least five times as frequent a
factor as is heredity; that at least eight-tenths of the
cases occurring in the children of tuberculous parents
are probably due to the direct communication of the
disease, and that if the spread of the infection could
be prevented, the element of heredity could be prac-
tically disregarded.

We are inclined to regard even the well-marked
tendency of tuberculosis to attack a considerable num-
ber of the members of a given family to be due largely,
in the first place, to direct infection; secondly, to the
fact that that family were all submitted to the same
unfavorable environment in the matter of food, of
housing, of overwork, or of the New England con-
science, with its deadly belief that " Satan finds some
mischief still for idle hands to do."

Upon direct pathological grounds nothing is more
definitely proven than that the actual inheritance of
tuberculosis, in the sense of its transmission from a
consumptive mother to the unborn child, is one of the
rarest of occurrences. On the other hand, the feeling
is general that, inasmuch as probably four-fifths of us
are repeatedly exposed to the infection of tuberculosis
and throw it off without developing a systemic attack

TUBERCULOSIS 173

of the disease, the development of a generalized infec-
tion, such as we term consumption, is in itself a sign
of a resisting power below the average. Should such
an individual as this become a parent, the strong prob-
ability is that his children — unless, as fortunately
often happens, their other parent should be as far above
the average of vigor and resisting power — would not
be likely to inherit more vigor than that possessed by
their ancestry. So that upon a priori grounds we should
expect to find that the children born of tuberculous
parents would be more susceptible to the infection
to which they are so sure to be exposed than the aver-
age of the race. So that the marriage of consumptives
should, unquestionably, upon racial grounds, be dis-
couraged except after they have made a complete re-
covery and remained well at least five years.

To sum up: while the earlier steps of civilization
unquestionably provide that environment which is
necessary for the development of tuberculosis, the later
stages, with their greatly increased power over the
forces of nature, their higher intelligence and their
broader humanity, not merely have it in their power to
destroy it, but are already well on the way to do so.

CHAPTER VIII

THE GREAT SCOURGE

NOT only have most diseases a living cause, and
a consequent natural history and course, but they
have a special method of attack, which looks almost
like a preference. It seems little wonder that the terror-
stricken imagination of our Stone Age ancestors should
have personified them as demons, " attacking" or leap-
ing upon their victims and "seizing" them with ma-
levolent delight. The concrete comparison was ready
to their hand in the attack of fierce beasts of prey;
and as the tiger leaps for the head to break the
neck with one stroke of his paw, the wildcat flies at the
face, the wolf springs for the slack of the flank or the
hamstring, so these different disease demons appear
each to have its favorite point of attack : smallpox, the
skin ; cholera, the bowels ; the Black Death, the arm-
pits and the groin ; and pneumonia, the lung.

There are probably few diseases which are so clearly
recognized by every one and about which popular
impressions are in the main so clear-cut and so correct
as pneumonia. The stabbing pain in the chest, the
cough, the rusty or blood-stained expectoration, the
rapid breathing, all stamp it unmistakably as a disease
of the lung. Its furious onset with a teeth-chattering
chill, followed by a high fever and flushed face, and its

THE GREAT SCOURGE 175

rapid course toward recovery or death, mark it off
sharply from all other lung infections.

Its popular names of " lung fever," " lung plague,"
" congestion of the lungs," are as graphic and distinc-
tive as anything that medical science has invented. In
fact, our most universally accepted term for it, pneu-
monia, is merely the Greek equivalent of the first of
these.

It is remarkable how many of our disease-enemies
appear to have a preference for the lung as a point of
attack. In the language of Old Man Means in "The
Hoosier Schoolmaster," the lung is " their fav'rit holt."
Our deadliest diseases are lung diseases, headed by con-*
sumption, seconded by pneumonia, and followed by
bronchitis, asthma, etc. ; together, they manage to ac-
count for one-fourth to -one-third of all the deaths that
occur in a community, young or old. No other great
organ or system of the body is responsible for more
than half such a mortality. Now this bad eminence has
long been a puzzle, since, foul as is the air or irritating
as is the gas or dust that we may breathe into our lungs,
they cannot compare for a moment with the awful con-
coctions in the shape of food which are loaded into our
stomachs. Even from the point of view of infections,
food is at least as likely to be contaminated with dis-
ease-germs as air is. Yet there is no disease or com-
bination of diseases of the whole food canal which has
half the mortality of consumption alone, in civilized
communities, while in the Orient the pneumonic form
of the plague is a greater scourge than cholera.

It has even been suggested that there may possibly

176 PREVENTABLE DISEASES

be a historic or ancestral reason for this weakness to
attack, and one dating clear back to the days of the
mud-fish. It is pointed out that the lung is the last of
our great organs to develop, inasmuch as over half of
our family tree is under water. When our mud-loving
ancestor, the lung-fish (who was probably "one of
three brothers" who came over in the Mayflower —
the records have not been kept) began to crawl out
on the tide-flats, he had every organ that he needed for
land-life in excellent working condition and a fair de-
gree of complexity: brain, stomach, heart, liver, kid-
neys; but he had to manufacture a lung, which he
proceeded to do out of an old swim-bladder. This,
of course, was several years ago. But the lung has not
quite caught up yet. The two or three million year lead
of the other organs was too much to be overcome all at
once. So carelessly and hastily was this impromptu
lung rigged up that it was allowed to open from the
front of the gullet or oesophagus, instead of the back,
while the upper part of the mouth was cut off for its
intake tube, as we have already seen in considering
adenoids, thus making every mouthful swallowed cut
right across the air-passages, which had to be provided
with a special valve-trap (the epiglottis) to prevent food
from falling into the lungs.

So, whenever you choke at table, you have a right
to call down a benediction upon the soul of your long
departed ancestor, the lung-fish. However applicable or
remote we may regard " the bearin's of this observa-
tion," the practical and most undesirable fact confronts
us to-day that this crossing and mutual interference of

THE GREAT SCOURGE 177

the air and the food-passages is a fertile cause of pneu-
monia, inasmuch as the germs of this disease have their
habitat in the mouth, and are from that lurking-place
probably inhaled into the lung, as is also the case with
the germs of several milder bronchitic and catarrhal
affections.

It may be also pointed out that, history apart, our
lung-cells at the present day are at another disadvan-
tage as compared with all the other cells of the body,
except those of the skin ; and that is, that they are in
constant contact with air, instead of being submerged
in water. Ninety-five per cent of our body-cells are
still aquatic in their habits, and marine at that, and can
live only saturated with, and bathed in, warm saline
solution. Dry them, or even half-dry them, and they
die. Even the pavement-cells coating our skin sur-
faces are practically dead before they reach the air,
and are shed off daily in showers.

We speak of ourselves as " land animals," but it is
only our lungs that are really so. All the rest of the
body is still made up of sea creatures. It is little wonder
that our lungs should pay the heaviest penalty of our
change from the warm and equable sea water to the
gusty and changeable air.

Even if we have set down the lung as a point of
the least resistance in the body, we have by no means
thereby explained its diseases. Our point of view has
distinctly shifted in this respect within recent years.
Twenty years ago pathologists were practically content
with tracing a case of illness or death to an inflamma-
tion or disease of some particular organ, like the heart,

178 PREVENTABLE DISEASES

the kidney, the lung, or the stomach. Now, however,
we are coming to see that not only may the causation
of this heart disease, kidney disease, lung disease, have
lain somewhere entirely outside of the heart, kidney,
or lung, but that, as a rule, the entire body is affected
by the disease, which simply expresses itself more
violently, focuses, as it were, in this particular organ.
In other words, diseases of definite organs are most
commonly the local expressions of general diseases or
infections; and this local aggravation of the disease
would never have occurred if the general resisting
power and vigor of the entire body had not been de-
pressed below par. So that even in guarding against or
curing a disease of a particular organ it is necessary to
consider and to treat the whole body.

Nowhere is this new attitude better illustrated than in
pneumonia. Frank and unquestioned infection as it is,
wreaking two-thirds of its visible damage in the lung
itself, the liability to its occurrence and the outlook for
its cure depend almost wholly upon the general vigor
and rallying power of the entire body. It is perfectly
idle to endeavor to avoid it by measures directed
toward the protection of the lung or of the air-passages,
and equally futile to attempt to arrest its course by
treatment directed to the lung, or even the chest. The
best place to wear a chest-protector is on the soles of
the feet, and poulticing the chest for pneumonia is
about as effective as shampooing the scalp for brain-
fag.

This clears the ground of a good many ancient mis-
conceptions; for instance, that the chief cause of

THE GREAT SCOURGE 179

pneumonia is direct exposure to cold or a wetting, or
the inhalation of raw, cold air. Few beliefs were more
firmly fixed in the popular mind — and, for the matter of
that, in the medical — up to fifteen or twenty years ago.
It has found its way into literature ; and the hero of the
shipwreck in an icy gale or of weeks of wandering in
the Frozen North, who must be offered up for artistic
reasons as a sacrifice to the plot, invariably dies a vic-
tim of pneumonia, from his "frightful exposure," just
as the victim of disappointed love dies of "a broken
heart," or the man who sees the ambitions of years
come crashing about his ears, or the woman who has
lost all that makes life worth living, invariably develops
"brain fever."

There is a physical basis for all of these standard
catastrophes, but it is much slenderer than is usually
supposed. For instance, almost every one can tell you
how friends of theirs have " brought on congestion of
the lungs," or pneumonia, by going without an over-
coat on a winter day, or breaking through the ice when
skating, or even by getting their feet wet and not chang-
ing their stockings; and this single dramatic instance
has firmly convinced them that the chief cause of
" lung fever " is a chill or a wetting. Yet when we come
to tabulate long series of causes, rising into thousands,
we find that the percentage in which even the patients
themselves attribute the disease to exposure, or a chill,
sinks to a surprisingly small amount. For instance,
in the largest series collected with this point in mind,
that of Musser and Norris, out of forty-two hundred
cases only seventeen per cent gave a history of exposure

180 PREVENTABLE DISEASES

and "catching cold"; and the smaller series range
from ten to fifteen per cent. So that, even in the face of
the returns, not more than one-fifth of all cases of
pneumonia can reasonably be attributed to chill.
And when we further remember that under this head-
ing of exposure and " catching cold " are included many
mere coincidences and the chilly sensations attending
the beginning of those milder infections which we term
"common colds," it is probable that even this small
percentage could be reduced one-half. Indeed, most
cautious investigators of the question have expressed
themselves to this effect. This harmonizes with a
number of obstinate facts which have long proved stum-
bling-blocks in the way of the theory of exposure as a
cause of pneumonia. One of the classic ones was that,
during Napoleon's frightful retreat from Moscow in the
dead of winter, while his wretched soldiers died by
thousands of frost-bite and starvation, exceedingly little
pneumonia developed among them. Another was that,
as we have already seen with colds, instead of being
commoner and more frequent in the extreme Northern
climate and on the borders of the Arctic Zone, pneu-
monia is almost unknown there. Of course, given the
presence of the germ, prolonged exposure to cold may
depress the vital powers sufficiently to permit an attack
to develop.

Again, the ages at wrhich pneumonia is both most
common and most deadly, namely, under five and over
sixty-five, are precisely those at which this feature of ex-
posure to the weather plays the most insignificant part.
Last and most conclusive of all, since definite statistics

THE GREAT SCOURGE 181

have begun to be kept upon a large scale, pneumonia
has been found to be emphatically a disease of cities,
instead of country districts. Even under the favorable
conditions existing in the United States, for instance,
the death-rate per hundred thousand living, according
to the last census, was in the cities two hundred and
thirty-three, and for the country districts one hundred
and thirty-five, — in other words, nearly seventy per
cent greater in city populations.

How, then, did the impression become so widely
spread and so firmly rooted that pneumonia is chiefly
due to exposure ? Two things, I think, will explain
most of this. One is, that the disease is most com-
mon in the winter- time, the other, that like all febrile
diseases it most frequently begins with sensations of
chilliness, varying all the way from a light shiver to
a violent chill, or rigor. The savage, bone-freezing,
teeth-rattling chill which ushers in an attack of pneu-
monia is one of the most striking characteristics of the
disease, and occurs in twenty-five to fifty per cent of all
cases.

Its chief occurrence in the winter-time is an equally
well-known and undisputed fact, and it has been for
centuries set down in medical works as one of the dis-
eases chiefly due to changes in temperature, humidity,
and directions of the wind. Years of research have
been expended in order to trace the relations between
the different factors in the weather and the occurrence
of pneumonia, and volumes, yes, whole libraries, pub-
lished, pointing out how each one of these factors, the
temperature, humidity, direction of wind, barometric

182 PREVENTABLE DISEASES

pressure, and electric tension, is in succession the prin-
cipal cause of the spread of this plague. Many interest-
ing coincidences were shown. But one thing always
puzzled us, and that was, that the heaviest mortality
usually occurred, not just at the beginning of winter,
when the shock of the cold would be severest, nor even
in the months of lowest temperature, like December
or January, but in the late winter and the early spring.
Throughout the greater part of the temperate zone
the death-rate for pneumonia begins to rise in Decem-
ber, increases in January, goes higher still in Febru-
ary, reaching its climax in that month or in March.
April is almost as bad, and the decline often does n't
fairly set in until May.

No better illustration could probably be given of the
danger of drawing conclusions when you are not in pos-
session of all the facts. One thing was entirely over-
looked in all this speculation until about twenty years
ago, — that pneumonia was due not simply to the de-
pressing effects of cold, but to a specific germ, the pneu-
mococcus of Fraenkel. This threw an entirely new light
upon our elaborate weather-causation theories. And
while these still hold the field by weight of authority
and that mental inertia which we term conservatism, yet
the more thoughtful physicians and pathologists are
now coming to regard these factors as chiefly important
according to the extent to which we are crowded to-
gether in often badly lighted and ill-ventilated houses
and rooms, with the windows and doors shut to save
fuel, thus affording a magnificent hothouse hatching-
ground for such germs as may be present, and ideal

THE GREAT SCOURGE 183

facilities for their communication from one victim to
another. At the same time, by this crowding and the
cutting off of life and exercise in the open air which
accompanies it, the resisting power of our bodies is low-
ered. And when these two processes have had an oppor-
tunity of progressing side by side for from two to three
months; when, in other words, the soil has been care-,
fully prepared, the seed sown, and the moist heat applied
as in a forcing-house, then we suddenly reap the har-
vest. In other words, the heavy crop of pneumonia in
January, February, and March is the logical result of
the seed-sowing and forcing of the preceding two or
three months.

The warmth of summer is even more depressing in its
immediate effects than the cold of winter, but the heat
carries with it one blessing, in that it drives us, willy-
nilly, into the open air, day and night. And on looking
at statistics we find precisely what might have been ex-
pected on this theory, that the death-rate for pneu-
monia is lowest in July and August.

It might be said in passing that, in spite of our vivid
dread of sunstroke, of cholera, and of pestilence in hot
weather, the hot months of the year in temperate cli-
mates are invariably the months of fewest diseases and
fewest deaths. Our extraordinary dread of the summer
heat has but slender rational physical basis. It may
be but a subconscious after-vibration in our brain cells
from the simoons, the choleras, and the pestilences of
our tropical origin as a race. Open air, whether hot,
cold, wet, dry, windy, or still, is our best friend, and
house air our deadliest enemy.

184 PREVENTABLE DISEASES

If this view be well founded, then the advance of
modern civilization would tend to furnish a more and
more favorable soil for the spread of this disease. This,
unfortunately, is about the conclusion to which we are
being most unwillingly driven. Almost every other
known infectious disease is diminishing, both in fre-
quency and in fatality, under civilization. Pneumonia
alone defies our onslaughts. In fact, if statistics are to
be taken at their surface-value, we are facing the appal-
ling situation of an apparently marked increase both
in its prevalence and in its mortality. For a number
of years past, ever since, in fact, accurate statistics
began to be kept, pneumonia has been listed as the
second heaviest cause of death, its only superior being
tuberculosis.

About ten years ago it began to be noticed that the
second competitor in the race of death was overtaking
its leader, and this ghastly rivalry continued until about
three years ago pneumonia forged ahead. In some
great American cities it now occupies the bad eminence
of the most fatal single disease on the death-lists,

The situation is, however, far from being as serious
and alarming as it might appear, simply from this bald
statement of statistics. First of all, because the forging
ahead of pneumonia has been due in greater degree
to the falling behind of tuberculosis than to any actual
advance on its part. The death-rate of tuberculosis
within the last thirty years has diminished between
thirty and forty per cent ; and pneumonia at its worst
has never yet equaled the old fatality of tuberculosis.
Furthermore, all who have carefully studied the subject

THE GREAT SCOURGE 185

are convinced that much of this apparent increase is
due to more accurate and careful diagnosis. Up to ten
years or so ago it was generally believed that pneu-
monia was rare in young children. Now, however,
that we make the diagnosis with a microscope, we dis-
cover that a large percentage of the cases of capillary
bronchitis, broncho-pneumonia, and acute congestion
of the lung in children are due to the presence of the
pneumococcus. Similarly, at the other end of the line,
deaths that were put down to bronchitis, asthma, heart
failure, yes, even to old age, have now been shown on
bacteriological examination to be due to this ubiqui-
tous imp of malevolence; so that, on the whole, all
that we are probably justified in saying is that pneu-
monia is not decreasing under civilization. This is
not to be wondered at, inasmuch as the inevitable
crowding and congestion which accompanies civiliza-
tion, especially in its derivative sense of " citification,"
tends to foster it in every way, both by multiplying the
opportunities for infection and lowering the resisting
power of the crowded masses.

Moreover, it was only in the last ten years, yes,
within the last five years, that we fairly grasped the
real method and nature of the spread of the disease,
and recognized the means that must be adopted against
it. And as all of these factors are matters which are
not only absolutely within our own control, but are
included in that programme of general betterment of
human comfort and vigor to which the truest intelli-
gence and philanthropy of the nation are now being
directed, the outlook for the future, instead of being
gloomy, is distinctly encouraging.

186 PREVENTABLE DISEASES

Our chief difficulty in discovering the cause of pneu-
monia lay in the swarm of applicants for the honor.
Almost every self-respecting bacteriologist seemed to
think it his duty to discover at least one, and the abun-
dance and variety of germs constantly or accidentally
present in the human saliva made it so difficult posi-
tively to isolate the real criminal that, although it was
identified and described as long ago as 1884 by Fraen-
kel, the validity of its claim was not generally recog-
nized and established until nearly ten years later.

It is a tiny, inoffensive-looking little organism, of an
oval or lance-head shape, which, after masquerading
under as many aliases as a confidence man, has finally
come to be called the pneumococcus, for short, or
"lung germ." Though by those who are more precise
it is still known as the Diplococcus pneumonias or
Diplococcus lanceolatus, from its faculty of usually ap-
pearing in pairs, and from its lance-like shape. Its
conduct abounds in "ways that are dark and tricks
that are vain," whose elucidation throws a flood of
light upon a number of interesting problems in the
spread of disease.

First of all, it literally fulfills the prognostic of Scrip-
ture, that " a man's foes shall be they of his own house-
hold," for its chosen abiding place and normal habitat
is no less intimate a place than the human mouth. Out-
side of this warm and sheltering fold it perishes quickly,
as cold, sunlight, and dryness are alike fatal to it.

We could hardly believe the evidence of our senses
when studies of the saliva of perfectly healthy indi-
viduals showed this deadly little bacillus to be present

THE GREAT SCOURGE 187

in considerable numbers in from fifteen to forty-five
per cent of the cases examined. Why, then, does not
every one develop pneumonia? The answer to this
strikes the keynote of our modern knowledge of infec-
tious disease, namely, that while an invading germ
is necessary, a certain breaking down of the body de-
fenses and a lowering of the vital resistance are equally
necessary. These invaders lie in wait at the very gates
of the citadel, below the muzzles of our guns, as it were,
waiting for some slackening of discipline or of watch-
fulness to rush in and put the fortress to sack. Nowhere
is this more strikingly true than in pneumonia. It is
emphatically a disease where, in the language of the
brilliant pathologist-philosopher Moxon, "While it is
most important to know what kind of a disease the
patient has got, it is even more important to know
what kind of a patient the disease has got."

The death-rate in pneumonia is an almost mathemat-
ically accurate deduction from the age, vigor, and nutri-
tion of the patient attacked. No other disease has such
a brutal and inveterate habit of killing the weaklings.
The half-stifled baby in the tenement, the underfed,
overworked laboring man, the old man with rigid ar-
teries and stiffening muscles or waning life vigor, the
chronic sufferer from malnutrition, alcoholism, Bright's
disease, heart disease — these are its chosen victims.

Another interesting feature about the pneumococcus
is its vitality outside of the body. If the saliva in which
it is contained be kept moist, and not exposed to the
direct sunlight and in a fairly warm place, it may sur-
vive as long as two weeks. If dried, but kept in the

188 PREVENTABLE DISEASES

dark, it will survive four hours. If exposed to sunlight,
or even diffuse daylight, it dies within an hour. In
other words, under the conditions of dampness and
darkness which often prevail in crowded tenements
it may remain alive and malignant for weeks ; in de-
cently lighted and ventilated rooms, less than two
hours. This explains why, in private practice and
under civilized conditions, epidemics of this admittedly
infectious disease are rare ; while in jails, overcrowded
barracks, prison ships, and winter camps of armies in
the field they are by no means uncommon. This is
vividly supported by the fact brought out in our later
investigations of the sputum of slum-dwellers, carried
out by city boards of health, that the percentage of
individuals harboring the pneumococcus steadily in-
creases all through the winter months, from ten per
cent in December to forty-five, fifty, and even sixty
per cent in February and March. The old proverb,
"When want comes in at the door, Love flies out at
the window," might be revised to read, " When sunlight
comes in at the window the pneumococcus flies * up
the flue.'"

Authorities are still divided as to the meaning and
even the precise frequency of the occurrence of the
pneumococcus in the healthy human mouth. Some
hold that its presence is due to recent infection which
has either been unable to gain entrance to the system
or is preparing its attack; others, that it is a survival
from some previous mild attack of the disease, and the
body tissues having acquired immunity against it,
it remains in them as a harmless parasite, as is now

THE GREAT SCOURGE 189

well known to be the case with the germs of several
of our infectious diseases — for instance, typhoid -
for months and even years afterward. Others hold the
highly suggestive view that it is a normal inhabitant
of the healthy mouth, which can become injurious
to the body, or pathogenic, only under certain depressed
or disturbed conditions of the latter. In defense of this
last it may be pointed out that dental bacteriologists
have now already isolated and described some thirty
different forms of organisms which inhabit the mouth
and teeth ; and the pneumococcus may well be one of
these. Further, that a number of our most dangerous
disease germs, like the typhoid bacillus, the bacillus of
tuberculosis, and the bacillus of diphtheria, have almost
perfect "doubles," law-abiding relatives, so to speak,
among the germs that normally inhabit our throats,
our intestines, or our immediate surroundings. The
ultimate foundation question of the science of bacteri-
ology is, How did the disease germs become disease
germs ? But the question is still unanswered.

However, fortunately, here, as in other human
affairs, imperfect as our knowledge is, it is sufficient
to serve as a guide for practical conduct. Widely pre-
sent as the pneumococcus is, we know well that it is
powerless for harm except in unhealthful surroundings.
There is another interesting feature of its life history
which is of practical importance, and that is, like many
other bacilli it is increased in virulence and infectious-
ness by passing through the body of a patient. Flushed
with victory over a weakened subject, it acquires cour-
age to attack a stronger. This is the reason why,

190 PREVENTABLE DISEASES

in those comparatively infrequent instances in which
pneumonia runs through a family, it is the strongest
and most vigorous members of the family who are the
last to be attacked. It also explains one of the para-
doxes of this disease, that, while emphatically a disease
of overcrowding and foul air, and attacking chiefly
weakened individuals, it is a veritable scourge of
camps, whether mining or military. When once three
or four cases of pneumonia have occurred in a mining
camp, even though this consist almost exclusively of
vigorous men, most of them in the prime of life, it
acquires a virulence like that of a pestilence, so that,
while ordinarily not more than fifteen to twenty per
cent of those attacked die, death-rates of forty, fifty,
and even seventy per cent are by no means uncommon
in mining camps. The fury and swiftness of this
"miners' pneumonia" is equally incredible. Strong,
vigorous men are taken with a chill while working in
their sluicing ditches, are delirious before night, and
die within forty-eight hours. So widely known are these
facts, and so dreaded is the disease throughout the Far
West and in mountain regions generally, that there is
a widespread belief that pneumonia at high altitudes
is particularly deadly.

I had occasion to interest myself in this question
some years ago, and by writing to colleagues practicing
at high elevations and collecting reports from the liter-
ature, especially of the surgeons of army posts in
mountain regions, was somewhat surprised to find that
the mortality of all cases occurring above five thousand
feet elevation was almost identical with that of a similar

THE GREAT SCOURGE 191

class of the population at sea-level. It is only when a
sufficient number of cases occur in succession to raise
the virulence of the pneumococcus in this curious man-
ner that an epidemic with high fatality develops.

That this increase in virulence in the organism does
occur was clearly demonstrated by a bacteriologist
friend of mine, who succeeded in securing some of
the sputum from a fatal case in the famous Tonopah
epidemic of some years ago, an epidemic so fatal that
it was locally known as the "Black Death." Upon
injecting cultures from this sputum into guinea-pigs,
the latter died in one-quarter of the time that it usually
took them to succumbto a similar dose of an ordinary
culture of the pneumococcus.

It is therefore evident that just as "no chain is
stronger than its weakest link," so in the broad sense
no community is stronger than its weakest group of
individuals, and pneumonia, like other epidemics,
may be well described as the vengeance which the
"submerged tenth" may wreak from time to time
upon their more fortunate brethren.

Now that we know that under decent and civilized
conditions of light and ventilation the pneumococcus
will live but an hour to an hour and a half, this re-
duces the risk of direct infection under these conditions
to a minimum. It is obvious that the principal factors
in the control of the disease are those which tend to
build up the vigor and resisting power of all possible
victims. The more broadly we study the disease the
more clearly do the data point in this direction.

First of all, is the vivid and striking contrast between

192 PREVENTABLE DISEASES

hospital statistics and those gathered from private
practice. While many individuals of a fair wage-
earner's income and good bodily vigor are treated in
our hospitals, yet the vast majority of hospital patients
are technically known as the "hospital classes," apt
to be both underfed, overworked, and overcrowded.
On the other hand, while a great many both of the
very poor and even of the destitute are treated in private
practice, yet the majority of such cases who feel " able
to afford a doctor," as they say, are among the com-
paratively vigorous, well-fed, and well-housed section
of the community. And the difference between the
death-rate of the two classes in pneumonia is most
significant. In private practice, while epidemics differ
in virulence, the rate ranges all the way from five per
cent to fifteen per cent, the average being not much in
excess of ten per cent, occasionally falling as low as
three per cent. In the hospital reports on the contrary
the death-rate begins at twenty per cent and climbs to
thirty, forty, and forty-five per cent. It is only fair to
say, of course, that hospital statistics probably include
a larger percentage of more serious cases, the milder
ones being taken care of at home, or not presenting
themselves for treatment at all. But even when this
allowance has been made, the contrast is convincing.
A similar influence is exercised by age. Although
pneumonia is common at all ages, its heaviest death-
rate falls at the two extremes, under six years of age
and over sixty, with a strong preponderance in the
latter. Under five years of age, the mortality may reach
twenty to thirty per cent ; from five to twenty-five, not

THE GREAT SCOURGE 193

more than four to five per cent ; from twenty-five to
thirty-five, from fifteen to twenty per cent ; and so on,
increasing gradually with every decade until by sixty
years of age the mortality has reached fifty per cent,
and from sixty to seventy-five may be expressed in
terms of the age of the patient. One consoling feature,
however, about it is that its mortality is lowest in the
ages at which it is most frequent, namely, from ten
to thirty-five years of age. And its frequency dimin-
ishes even more rapidly than its fatality increases in
later years. So that while it is much more serious in
a middle-aged man, he is less liable to develop it than
a younger one. Where the mortality from pneumonia is
highest, is in the most densely populated wards, espe-
cially among negroes and foreigners of the hospital
class, in individuals who are victims of chronic alco-
holism, and also among those who are for long periods
insufficiently nourished. Lastly, it is only within com-
paratively recent years that we have come clearly to
recognize the large role which pneumonia plays in
giving the finishing stroke to chronic diseases and de-
generative processes. It is, for instance, one of the
commonest actual causes of death in Bright's dis-
ease, in diabetes, in lingering forms of tuberculosis, and
in heart disease; and last of all, in that progressive pro-
cess of normal degeneration and decay which we term
" Old Age." It is one of the most frequent and fatal of
what Flexner described a decade ago as "terminal
infections." Very few human beings die by a gradual
process of decay, still less go to pieces all at once, like
the immortal " One-Hoss Shay." Just as soon as the

194 PREVENTABLE DISEASES

process has progressed far enough to lower the resist-
ing power below a certain level, some acute infection
steps in and mercifully ends the scene. This is pecu-
liarly true of pneumonia in old age.

To the medical profession to "die of old age" is
practically equivalent to dying of pneumonia. The
disease is so mild in its symptoms and so rapid in
its course that it often utterly escapes recognition as
such.

The old man complains of a little pain in his chest,
a failure of appetite, a sense of weakness and dizziness.
He takes to his bed, within forty-eight hours he be-
comes unconscious, and within twenty-four more
he is peacefully breathing his last. After death, two-
thirds of the lung will be found consolidated. So mild
and rapid and painless is the process that one phy-
sician-philosopher actually described pneumonia as
"the friend of old age.'*

When once the disease has obtained a foothold in
the body its course, like one of Napoleon's campaigns,
is short, sharp, and decisive. Beginning typically with a
vigorous chill, sometimes so suddenly as to wake the
patient out of a sound sleep, followed by a stabbing
pain in the side, cough, high fever, rapid respiration, the
sputum rusty or orange-colored from leakage of blood
from the congested lung, within forty-eight hours the
attacked area of the lung has become congested; in
forty-eight more, almost solidified by the thick, sticky
exudate poured out from the blood-vessels, which co-
agulates and clots in the air cells. So complete is this
solidification that sections of the attacked lung, instead

THE GREAT SCOURGE 195

of floating in water as normal lung-tissue will, sink
promptly. The severe pain usually subsides soon, but
the fever, rapid respiration, flushed face, with or with-
out delirium, will continue for from three to seven or
eight days. Then, as suddenly as the initial attack,
comes a plunge down of the temperature to normal.
Pain and restlessness disappear, the respiration drops
from thirty-five or forty to fifteen or twenty per minute,
and the disease has practically ended by "crisis." Nat-
urally, after such a furious onslaught, the patient is apt
to be greatly weakened. He may have lost twenty or
thirty pounds in the week of the fever, and from one to
three weeks more in bed may be necessary for him to
regain his strength. But the chief risk and danger
are usually over within a week or ten days at the out-
side.

Violent and serious as are the changes in the lung,
it is very seldom that death comes by interference with
the breathing space. In fact, while regarded as a lung
disease, we are now coming to recognize that the actual
cause of death in fatal cases is the overwhelming of the
heart by the toxins or poisons poured into the circu-
lation from the affected lung. The mode of treatment
is, therefore, to support the strength of the patient in
every way, and measures directed to the affected lung
are assuming less and less importance in our arsenal
of remedies. Our attitude is now very similar to that
in typhoid, to support the strength of the patient by
judicious and liberal feeding, to reduce the fever and
tone up his blood-vessels by cool sponging, packing,
and even bathing; to relieve his pain by the mildest

196 PREVENTABLE DISEASES

possible doses of sedatives, knowing that the disease is
self-limited, and that in patients in comfortable sur-
roundings and fair nutrition from eighty to ninety per
cent will throw off the attack within a week. So com-
pletely have we abandoned all idea of medicating or
protecting the lung as such, that in place of over-
heated rooms, loaded with vapor by means of a steam
kettle, for its supposed soothing effect upon the in-
flamed lung, we now throw the windows wide open.
And some of our more enthusiastic clinicians of wide
experience are actually introducing the open-air cure,
which has worked such wonders in tuberculosis, in the
treatment of pneumonia. In more than one of our New
York hospitals now, particularly those devoted to the
care of children, following the brilliant example of
Dr. William Northrup, wards are established for pneu-
monia cases out on the roof of the hospital, even when
the snow is banked up on either side, and the covering
is a canvas tent. Nurses, physicians, and ward attend-
ants are clothed in fur coats and gloves, the patients
are kept muffled up to the ears, with only the face ex-
posed ; but instead of perishing from exposure, little,
gasping, struggling tots, whose cases were regarded as
practically hopeless in the wards below, often fall into
the sleep that is the turning point toward recovery
within a few hours after being placed in this winter
roof -garden.

In short, our motto may be said to be, "Take
care of the patient, and the disease will take care of
itself."

Though pneumonia is one of our most serious and

THE GREAT SCOURGE 197

most fatal of diseases, yet it is one over whose cause,
spread, and cure we are obtaining greater and greater
control every day, and which certainly should, within
the next decade, yield to our attack, as tuberculosis and
typhoid are already beginning to do.

CHAPTER IX

THE NATURAL HISTORY OF TYPHOID FEVER

WHY should not a disease have a natural history,
as well as an individual ? At first sight, this
might appear like a reversion to the old, crude theory of
disease as a demonic obsession, or invasion by an evil
spirit, of which traces still remain in such expressions
as, "She was seized with a convulsion," "He was
strong enough to throw off the illness," "He was at-
tacked by a fever," etc. But apart entirely from such
conceptions, which were perfectly natural in the in-
fancy of the race, while clearly recognizing that disease
is simply a perverted state of nutrition or well-being
in the body of the patient, a disturbance of balance,
so to say, yet it is equally true that it has a birth,
an ancestry, a life-course, and a natural termination,
or death.

This recognition of the natural causation and devel-
opment of disease has been one of the greatest tri-
umphs, not merely of pathology, but of intelligence
and rationalism. It has done more to diminish that
dread of the unknown wThich hangs like a black pall of
terror over the mind of the savage and the semi-civil-
ized mind than any other one advance. It contributes
enormously to our courage, our hopefulness, and our
power of protection in more ways than one: first of
all, by revealing to us the external cause of disease,

TYPHOID FEVER 199

usually some careless, dirty, or bad habit on the part
of an individual or of the community, and thus enabling
us to limit its spread and even exterminate it ; secondly,
by assuring us that nearly all diseases, excepting a few
of the most obstinate and serious, have not only a
definite beginning, but a definite end, are, in fact,
if left to themselves, self-limited, either by the exhaus-
tion and loss of virulence of their cause, or by the
resisting power of the body.

All infectious diseases, and many others, tend to
run a definite course of so many days, or so many
weeks, within certain limits, and at least ninety per
cent of them tend to terminate in recovery. It is a most
serious and fatal disease which has a death-rate of more
than twenty per cent. Typhoid, pneumonia, diph-
theria, and yellow fever all fall below this, smallpox
barely reaches it, and only the bubonic plague, cholera,
and lockjaw rise habitually above it. The recognition
of this fact has enormously increased the efficiency
of the medical profession in dealing with disease, by
putting us on the track of imitating the methods
which the body itself uses for destroying, or checking
the spread of, invading germs and leading us to trust
nature and try to work with her instead of against her.
Our antitoxins and anti-serums, which are our bright-
est hope in therapeutics at present, are simply antidotes
which are formed in the blood of some healthy, vigor-
ous animal against the bacillus whose virulence we wish
to neutralize, such as that of diphtheria or septicemia.

Diphtheria antitoxin, for instance, the first and best
known triumph of the new medicine, is the antidotal

200 PREVENTABLE DISEASES

substance formed in the blood of a horse in response
to a succession of increasing doses of the bacilli of diph-
theria. Similar antidotal substances are formed in the
blood in all other non-fatal cases of infectious diseases,
such as typhoid, pneumonia, blood-poisoning, etc. ; and
the point at which they have accumulated in sufficient
amounts to neutralize the poison of the invading germs,
forms the crisis, or " turn " of the disease. So that when
we speak of a disease " running its course," we mean
continuing for such length of time as the body needs to
produce anti-bodies in sufficient amounts to check it.

The principal obstacle to the securing of antitoxins
like that of diphtheria for all our infectious diseases is,
that their germs form their poison so slowly that it is
difficult to collect it in sufficient amounts to produce
a strong concentrated antitoxin in the animal into
which it is injected. But the overcoming of this diffi-
culty is probably only a question of time.

Obviously, if infectious disease be, as we say, " self-
limited," that is to say, if the body will defeat the in-
vaders with its own weapons, on an average in nine
cases out of ten, our wisest course, as physicians, is
to back up the body in its fight. This we now do in
every possible way, by careful feeding, by rest, by
bathing, by an abundance of pure water and fresh air,
with the gratifying result that we have already reduced
the death-rate in most fevers, even such as we have
no antitoxin against, or may not even have discovered
the causal germ of, to one-half and even three-fourths
of their former fatality. The recognition of the fact
that disease has a natural history, a birth, a term of

TYPHOID FEVER 201

natural life and a death, has already turned a hope-
less fight in the dark into a victorious campaign in
broad daylight. Huxley's pessimistic saying that
typhoid was like a fight in the dark between the dis-
ease and the patient, and the doctor like a man with
a club striking into the melee, sometimes hitting the
disease and sometimes the patient, is no longer true
since the birth of bacteriology.

Nowhere can the natural history of disease be more
clearly seen or more advantageously studied than in the
case of typhoid fever.

The cause of typhoid is simplicity itself, merely
drinking the excreta of some one else, "eating dirt,"
in the popular phrase; simple, but of a deadly effec-
tiveness, and disgracefully common. The demon may
be exorcised by an incantation of one sentence : Keep
human excreta out of the drinking water. This sounds
simple, but it is n't. Eternal vigilance is the price of
health as well as of liberty.

We can, however, make our pedigree of typhoid a
little more precise. It is not merely dirt of human origin
which is injurious, but dirt of a particular type,
namely, discharges from a previous case of the disease.
Just as in the fight against malaria we have not the
enormous problem of the extermination of all varieties
of mosquito, but only of one particular genus, and
only the infected specimens of that, so in typhoid,
the contamination of water or food which we have to
guard against is that from previous cases. From one
point of view, this leaves the problem as wide as
ever, for, obviously, the only way to insure against

202 PREVENTABLE DISEASES

poisoning of water by typhoid discharges is to shut out
absolutely all sewage contamination. On the other
hand, it is of immense advantage in this regard, — it
enables us to fight the enemy at both ends of the line,
to turn his flank as well as crush his centre.

While we are protecting our water-supplies against
sewage, we can, in the meantime, render that sewage
comparatively harmless by thoroughly disinfecting and
sterilizing all discharges from every known case of the
disease. A similar method is used in the fight against
yellow fever and malaria. Not only are the breeding
places of the two mosquito criminals broken up, but
each known case of the disease is carefully screened, so
as to prevent the insects from becoming infected, and thus
able to transmit the disease to other human victims.

It cannot be too emphatically insisted upon that
every case of typhoid, like every case of yellow fever
and of malaria, comes from a previous case. It is neither
healthy nor exhilarating to drink a clear solution of
sewage, no matter how dilute; but, as a matter of fact,
it is astonishing how long communities may drink
sewage-laden water with comparative impunity, so
long as the sewage contains no typhoid discharges.
One case of typhoid fever imported into a watershed
will set a city in a blaze.

The malevolent Deus in the sewage machina is, of
course, a germ — the Bacillus typhosus of Eberth. The
astonishing recentness of much of our most important
knowledge is nowhere better illustrated than in the
case of typhoid. Although there had been vague de-
scriptions of a fatal fever, slow and lingering in its

TYPHOID FEVER 203

character and accompanied by prolonged stupor and
delirium, which was associated with camps and dirty
cities and famines, from as far back as the age of Caesar,
the first description clear enough to be recognizable
was that of Willis, of an epidemic during the English
civil war in 1643, both Royalist and Roundhead armies
being seriously crippled by it. Since that time a smoul-
dering, slowly spreading fever has been pretty con-
stantly associated with armies in camps, besieged cities,
filthy jails, and famines, to which accordingly have
been given the names, familiar in historical literature,
of "famine fever," "jail fever," and "military fever."

So slowly, however, did accurate knowledge come,
that 'it was actually not until 1837 that it was clearly
and definitely recognized that this famine fever was,
like Mrs. Malaprop's Cerberus, " two gentlemen at
once," one form of it being typhus or "spotted
fever," which has now become almost extinct in civ-
ilized communities; the other, the milder, but more
persistent form, which, like the poor, wTe have always
with us, called, from its resemblance to the former,
"typhoid" (typhus-like).

Typhus was a far more virulent, rapid, and fatal fever
than its twin survivor, though as to the relations be-
tween the two diseases, if any, we are quite in the dark,
as the former practically disappeared before the days
of bacteriology. The fact of its disappearance is both
significant and interesting, in that it was unquestion-
ably due to the ranker and viler forms of both munici-
pal and individual filthiness and unsanitariness, which
even our moderate progress in civilization has now

204 PREVENTABLE DISEASES

abolished. There can be no question that, with a
step higher in the scale of cleanliness, and further
quickening of the biologic conscience, typhoid will also
disappear.

Typhus, the bubonic plague, the sweating sickness,
were alike plagues and products of times when table-
scraps were thrown on the dining-room floor and
covered daily with fresh rushes for a week at a stretch,
and fertilizer accumulated in a living-room as now in
a modern stable. Clothing was put on for the season,
shirts were unknown, and strong perfumes took the
place of a bath. Michelet's famous characterization of
the Middle Ages in one phrase as Un mille ans sans bain
(a thousand years without a bath) was painfully ac-
curate.

Doubtless certain habits of our own to-day will be
regarded with equal disgust by our descendants. Ty-
phus, by the way, may possibly be remembered by the
dramatic "Black Assize" of Oxford, in 1577, in which
not merely the wretched prisoners in the jail, but the
jurors, the lawyers, the judges, and every official of the
court were attacked, and many of them died.

It was only in 1856 that the method of transmission
of the disease was clearly recognized, and in 1880 that
the bacillus was discovered and identified by the bac-
teriologist Eberth, whose name it bears, so that it is
only within the last thirty years that real weapons have
been put into our hands with which to begin a fight of
extermination against the disease.

What is the habitat of our organism, and is it in-
creasing its spread ? Its habitat is the entire civilized

TYPHOID FEVER 205

world, and it goes wherever civilization goes. In this
sense its spread is increasing, but, in every other, we
have good ground for believing that it is on the wane".
Positive assurance, either one way or the other, is,
of course, impossible, simply for the reason that the
disease was not recognized until such a short time ago
that no statistics of any real value for comparison are
available; and, secondly, because even to-day, on
account of its insidious character and the astonishing
variety of its forms, and degrees of mildness and viru-
lence, a considerable percentage of cases are yet un-
recognized and unreported.

It might be mentioned in passing that this statement
applies to the alleged increase of nearly all diseases
which are popularly believed to be modern inventions,
like appendicitis, insanity, and cancer. We have no
statistics more than thirty years old which are of real
value for purposes of comparison.

However, when it comes to the number of deaths
from the disease, there is a striking and gratifying
diminution for twenty years past, which is increasing
in ratio instead of diminishing. That we are really get-
ting control of typhoid is shown by the, at first sight,
singular and decidedly unexpected fact that it is no
longer a disease of cities, but of the country. The death-
rate per thousand living in the cities of the United States
is lower than in the rural districts. For instance, the
mortality in the State of Maryland, outside of Balti-
more, is two and one-half times as great as that in the
city itself. Our period of greatest outbreak in the large
cities is now the month of September, when city dwell-

206 PREVENTABLE DISEASES

ers have just returned from their vacations in the pure
and healthful country, bringing the bacilli in their
systems.

The moral is obvious. Great cities are developing
some sort of a sanitary conscience. Farmers and
country districts have as yet little or none. Bad as our
city water often is, and defective as our systems of
sewage, they cannot for a moment compare in deadli-
ness writh that most unheavenly pair of twins, the
shallow well and the vault privy. A more ingenious
combination for the dissemination of typhoid than this
precious couple could hardly have been devised. The
innocent householder sallies forth, and at an appro-
priate distance from his cot he digs two holes, one
about thirty feet deep, the other about four. Into the
shallower one he throws his excreta, while upon the
surface of the ground he flings abroad his household
waste from the back stoop. The gentle rain from heaven
wrashes these various products down into the soil and
percolates gradually into the deeper hole. When the
interesting solution has accumulated to a sufficient
depth, it is drawn up by the old oaken bucket or modern
pump, and drunk. Is it any wonder that in this progres-
sive and highly civilized country three hundred and
fifty thousand cases of typhoid occur every year, with
a death penalty of ten per cent ? Counting half of these
as workers, and the period of illness as two months,
which would be very moderate estimates, gives a loss
of productive working time equivalent to thirty thou-
sand years. Talk of "cheap as dirt"! It is the most
expensive thing there is.

TYPHOID FEVER 207

Typhoid still abundantly earns its old name of
"military fever," and its sinister victories in war are
even more renowned than its daily triumphs in peace.
Strange as it may seem, the deadliest enemies of the
soldier are not bullets but bacilli, and sewage is might-
ier than the sword. For instance, in the Franco-
Prussian War, typhoid alone caused sixty per cent of
all the deaths. In the Boer War it caused nearly six
thousand deaths as compared with seven thousand five
hundred from wounds in battle, while other diseases
caused five thousand more. In the majority of modern
campaigns, from two-thirds to five-sixths of all deaths
are due to disease and not to battle. It may be that we
sanitarians will achieve the ends of the peace congresses
by an unexpected route, and make war a healthful and
comparatively harmless form of national gymnastics.
Its battle- mortality rate, for the number engaged, is
not so very far above football now !

Given the bacillus, how does it get into the human
system ? Here the evidence is so abundant and over-
whelming that we may content ourselves with bald
statements of fact. The three great routes of this pesti-
lence are water, milk, and flies. Of the three, the first
is far the most common and important. While only a
rough statement is possible, probably eighty-five per
cent of all cases from water, five per cent from milk,
five per cent through flies, and five per cent through
other channels, would fairly represent the percentage.

That it is conveyed through water is as certain as
that the sun rises and sets. The only embarrassment
in proving it lies in selecting from the swarm of in-

208 PREVENTABLE DISEASES

stances. There is the classic case of the Swiss villages
on opposite sides of the same mountain chain, the
second of which drew its water-supply from a spring
that came through the mountain from a brooklet run-
ning by the first village. Typhoid fever broke out in the
first village, and twenty days later it appeared in the
second village, twenty miles away on the other side of
the mountain. Colored particles thrown into the brook
on one side promptly appeared in the spring upon
the other. Then there was the gruesome modern in-
stance of Plymouth, Pennsylvania, in 1885. A single
case of imported typhoid occurring on the watershed
of a reservoir was followed, thirty days later, by an
epidemic of eleven hundred cases in a population of
eight thousand.

An equally vivid instance came under my own obser-
vation. A school and a penitentiary drew their water-
supply from the same power-flume, carrying a superb
volume of purest water from a mountain stream. Early
in the autumn a single case of typhoid appeared in a
small town near the head of the flume. The discharges
were thrown into the swiftly running water. Two
weeks later an epidemic of typhoid broke out in the
school, and three weeks later in the penitentiary.
An unexpected freak, however, was the appearance
of fifteen or twenty cases in another state institution
farther down on the same stream, which did not draw
its water-supply from the flume, but from deep wrells of
tested purity. This was a puzzle, until it was found
that, owing to a fall in the wells, the water from the
flume had been used for sprinkling and washing pur-

TYPHOID FEVER 209

poses in the institution, being allowed to run through
the water-pipes only at night, while the well-water was
used in the daytime. This was enough to contaminate
the pipes, and a small epidemic began, which promptly
stopped as soon as the cause was suspected and the
flume-water no longer used.

This last instance is peculiarly interesting, as illus-
trating how typhoid infection gets into milk, the second
— though at a long interval — most frequent means
of its spread. It does not come from the cow, for,
fortunately, none of the domestic animals, with the
possible exception of the cat, is subject to typhoid.
Nor is it possible that cattle, drinking foul and even
infected water, can transmit the bacillus in their milk.
That superstition was exploded long ago. Every epi-
demic of typhoid spread by milk — and there are scores
of them now on record — can be traced to the handling
of the milk by persons suffering from mild forms of
typhoid, or engaged in waiting upon members of the
family who are ill of the disease, or the dilution of milk
with infected water, or even, almost incredible as it may
seem, to such slight contamination as washing the cans
with infected water.

Health officers now watch like hawks for the appear-
ance of any case of typhoid among or in the families
of dairymen. The New York City Board of Health, for
instance, requires the weekly filing of a certificate from
the family physician of all dairymen that no such cases
exist. And the more intelligent dairymen keep a vigi-
lant eye upon any appearance of illness accompanied
by fever among their employees, some that I have

210 PREVENTABLE DISEASES

known even keeping a fever thermometer in the barn
for the purpose of testing every suspicious case. How
effective such precautions can be made may be illus-
trated by the fact that, in the past five years, there has
not been a single epidemic of typhoid traceable to milk
in Greater New York, even with its inadequate corps
of ten inspectors, and the six states they have to cover.
The moment a single case of typhoid appears, the dairy
or milkman supplying that customer is given a most
rigid special inspection, and, if any source of infection
can be discovered, the milk is shut out of New York
City until the department is satisfied that all danger
has been removed. One or two lessons of this sort are
enough for a whole county of dairymen. The danger
of transmission of typhoid through milk has been enor-
mously exaggerated, and, as in the case of all other
milk-borne diseases, is entirely due to filthy handling,
and may be prevented by intelligent sanitary policing.
Even with our present exceedingly imperfect systems,
probably not more than between five and ten per cent
of typhoid is transmitted in this way ; and, if the water-
supply were kept clean, this would practically disap-
pear.

Typhoid may not only be transmitted from the earth
beneath and the water under the earth, but also from
the heavens above, through the medium of flies arid
dust. The first method is bulking larger every day,
especially in country districts and in camps. The
modus operandi is simplicity itself. The fly lives and
moves and has its being in dirt. It breeds in dirt and it
feeds on food, and, as it never wipes its feet, the interest-

TYPHOID FEVER 211

ing results can be imagined. Just to dispel any pos-
sible doubt, plates of gelatine have been exposed where
flies could walk on them, then placed in an incubator,
and within forty-eight hours there was a clearly re-
corded track of the footprints of the flies written in
clumps of bacilli sown by their filthy feet. More defi-
nitely, flies have been caught in the houses of typhoid
patients, put under the microscope, and their feet,
stomachs, and specks found swarming with typhoid
bacilli. A single flyspeck may contain three thousand.

Fortunately, we have a simple and effective remedy.
We cannot disinfect tjie fly nor make him wipe his
feet, but we can exterminate him utterly ! This sounds
difficult, but it is n't. Like the mosquito, the fly can
only breed in one particular kind of place, and that
place is a heap of dirt, preferably horse manure,
but, at a pinch, dust-bins, garbage-cans, sweepings
under porches or behind furniture, vaults, — anywhere
that dirt is allowed to remain undisturbed for more
than a week at a stretch. Abolish, screen, or poison
these dirt accumulations, and flies will disappear, and
with them not merely risks from typhoid, but half a
dozen other diseases, as well as all sorts of filth and
much discomfort and inconvenience. It was largely
through flies that the disgraceful epidemic of typhoid,
which ravaged our camps on our own soil during the
Spanish-American War and killed many times more
than fell by Spanish bullets, was spread.

It is also believed that typhoid bacilli may be carried
in the infected dust of streets and camps. Here again
we are dealing with a dangerous public enemy to both

212 PREVENTABLE DISEASES

health and comfort, which can and ought to be abated
by cleanliness, oilings, and sprinklings. Typhoid ba-
cilli are also occasionally carried by shellfish, especially
oysters, on account of the interesting modern custom
of planting them in bays and harbors near the mouths
of sewers to fatten them. The cheerful motto of the
oysterman is, "The muddier the water the fatter the
oyster." And nowhere do the bivalves plump up more
quickly than near the mouth of a sewer.

The last method of transmission is by direct contact
with the sick. This is a relatively rare means of spread,
so much so that it is generally stated that typhoid is
not contagious ; but it is a real source of danger and one
against which precautions should by all means be taken.
The only method is, of course, by the soiling of the
hands of the nurse or other attendant, and then eating
or touching food, or putting the fingers into the mouth
before thoroughly cleansing. If the hands be washed
with a strong antiseptic solution after waiting upon
the patient, and the cheerful habit sometimes indulged
in of putting fruit or other delicacies into the sick-room
for a day or so, in the hope that they may tempt the
appetite of the patient, and then taking them out and
letting the children eat them as a treat, be abolished,
and the nurse be not allowed to officiate in the kitchen,
risk from this source will be done away with.

When the bacillus has been introduced into the stom-
ach through food or drink, it rapidly proceeds to diffuse
itself throughout the tissues of the body. Because the
most striking symptoms of the disease are diarrhoea,
abdominal distention, and pain, and the most striking

TYPHOID FEVER 213

lesions after death ulcers in the small intestine, it was
supposed that the process was confined to the abdom-
inal organs. This is now known to be an error, as cul-
tures and examinations made from the blood and vari-
ous parts of the body have shown the presence of the
typhoid bacillus in almost every organ and tissue.
This process of scattering, or invasion of the body,
takes from three to ten days to accomplish; and the
first sign of trouble is usually a feeling of depression,
with headache, and perhaps slight nausea, before any
characteristic bowel symptoms begin to show them-
selves.

The general invasion of the system throws an inter-
esting sidelight upon the subject of premonitions.
There are several well authenticated cases on record
where individuals just before coming down with typhoid
have been strangely impressed with a sense of impend-
ing death, and have even gone so far as to make their
wills and set their affairs in order. Because these strong
impressions appeared before any clearly marked in-
testinal symptoms of the disease, they have been put
down in popular literature as instances of the "sec-
ond sight," or " sixth sense," which popular superstition
believes many of us to possess under certain circum-
stances. Now, however, we know that the tissues of
that individual were already swarming with bacilli, and
his fear of impending death was simply the effect of
his toxin-laden blood upon his brain centres. In other
words, it was prophecy after the fact, like nearly all
prophecies that happen to come true ; and the " pre-
monition" was an early symptom of the disease itself.

214 PREVENTABLE DISEASES

As it is, of course, difficult to fix the precise drink
of water or mouthful of food in which the infection was
conveyed, we were for a long time in doubt as to the
length of time which it took to spread through the sys-
tem, — the "period of incubation," as it is termed, —
although we knew in a general way that it averaged
somewhere about ten days. But, about a year ago,
fortune was kind to us. A nurse in one of the Parisian
hospitals, in a fit of despondency, decided to commit
suicide. Like a true Parisienne, she would be nothing
if not up to date, and chose, as the most recherche and
original method of departing this life, to swallow a pure
culture of typhoid germs, which she abstracted from
the laboratory. Three days later she began to complain
of headache, and within a week had developed a beauti-
ful crop of symptoms, and a typical case of typhoid,
from which, under modern treatment, she promptly
recovered, — a wiser and, we trust, a happier woman.

By just what avenue the infecting bacilli go from the
stomach into the general system we do not know.
Metschnikoff suggests that they can only penetrate
the intestinal wall through wounds or abrasions of the
mucous membrane, made by intestinal worms or other
parasites. Certain it is that the average stomach has a
considerable degree of resisting power against them,
for in no known civil epidemic has the number of those
who caught the disease exceeded ten per cent of the
total number drinking the infected water or milk.
In one or two camps in time of war the percentage
has risen as high as eighteen or twenty per cent of
those exposed, but this is exceptional. However, now

TYPHOID FEVER 215

that we know that intestinal symptoms do not con-
stitute the entire disease, and may even be entirely
absent, we strongly suspect that many cases of slight
depression, with feverishness, loss of appetite, and
disturbances of the digestion, which occur during an
epidemic, may really have been very mild cases of the
disease.

One of the singular features of the disease is that,
unlike many other infections, we are entirely unable to
say what conditions or influences seem either to pro-
tect against it or to predispose toward it. In the days
when we believed it to be an exclusively intestinal dis-
ease it was naturally supposed that chronic digestive
disturbances, and especially acute attacks of bowel
trouble or dysentery, would predispose to it, but this
has been entirely disproved. Soldiers in barracks with
chronic digestive disturbances, and even with dysen-
tery, have shown no higher percentage of typhoid dur-
ing an epidemic than others. Nor does it seem much
more likely to occur in those who are constitutionally
weak, or run down, or overworked, as some of the
most violent and unmanageable cases occur in vigor-
ous men and women, who were previously in perfect
health. So that, although we have unquestionably a
high degree of resistance against it, since not more than
one in ten exposed contracts it, and only one in ten of
those who contract it dies, we have not the least idea
in what direction, so to speak, to build up our resist-
ing powers in order to increase them.

The best remedy is to destroy the disease altogether,
and this could be done in five years by intelligent con-

216 PREVENTABLE DISEASES

certed effort. It was at one time supposed that typhoid
fever was a disease exclusively confined to adult life ;
but it is now known to occur frequently in children,
though often in such a mild and irregular form as to
escape recognition. Something like seventy per cent
of all cases occur between the fifteenth and the fortieth
year, and it is, for some reason, though rarer, peculiarly
serious and more often fatal after the fiftieth year.

When once the outer wall has been pierced, the sack
of the city rapidly proceeds. The bacilli multiply every-
where, but seem for some reason to focalize chiefly
in the alimentary canal, and especially the middle part
of it, the small intestines. After headache, backache,
and loss of appetite comes usually a mild diarrhoea.
This diarrhoea is due to an attack of the bacillus or its
toxins upon certain clumps of lymphoid tissue in the
wall of the small intestine, known as the "patches of
Peyer." This produces inflammation, followed by
ulceration, which in severe cases may eat through the
wall of a blood-vessel, causing profuse hemorrhages,
or even perforate the bowel wall and set up a fatal
peritonitis. The temperature begins to swing from
two to five degrees above the normal level, following
the usual daily vibration, and ranging from 100 degrees
to 101 degrees in the morning up to 102 degrees to 105
degrees in the afternoon. The face becomes flushed.

There is usually comparatively little pain, and the
patient lies in a sort of mild stupor, paying little atten-
tion to his surroundings. He is much enfeebled and
seldom cares to lift his head from the pillow. A slight
rash appears upon the surface of the body, but this

TYPHOID FEVER 217

is so faint that it would escape attention unless care-
fully looked for. Little groups of vesicles, containing
clear fluid, appear upon the chest and abdomen. If
one of these faint rose-colored spots be pricked with
a needle and a drop of blood be drawn, typhoid bacilli
will often be found in it, and they will also be present
in the clear fluid of the tiny sweat blisters.

This condition will last for from ten days to four
weeks, the patient gradually becoming weaker and
more apathetic, and the temperature maintaining an
afternoon level of 102 to 104 degrees. Then, in the vast
majority of cases, a little decline of the temperature
will be noticed. The patient begins to take a slight
interest in his surroundings. He will perhaps ask for
something to drink, or something to eat, instead of
apathetically swallowing what is offered to him. Next
day the temperature is a little lower still, and within
a week, perhaps, will have returned to the normal level.
The patient has lost from twenty to forty pounds, is
weak as a kitten, and it may be ten days after the fever
has disappeared before he asks to sit up in bed.

Then follows the period of return to health. The
patient becomes a walking appetite, and, after weeks
of liquid diet, will beg like a spoiled child for cookies
or hard apples or pie, or something that he can set his
teeth into. But his tissues are still swarming with the
bacilli, and any indiscretion, either of diet, exposure,
or exertion, at this time, may result in forming a sec-
ondary colony, or abscess, somewhere in the lungs, the
liver, or the muscles. He must be kept quiet and warm,
and abundantly, but judiciously, fed, for at least three

218 PREVENTABLE DISEASES

weeks after the disappearance of the fever, if he wishes
to avoid the thousand and one ambuscades set by the
retreating enemy.

Now, what has happened when recovery begins?
One would suppose that either the bacilli had poisoned
themselves, exhausted the supplies of nourishment in
the body of the patient, so that the fever had " burnt
itself out," as we used to say, or that the tissues had
rallied from the attack and destroyed or thrown out
the invaders. But, on the contrary, we find that our
convalescent patient, even after he is up and walking
about, is still full of the bacilli.

To put it very crudely, what has really happened is
that the body has succeeded in forming such antidotes
against the poison of the bacilli that, although they
may be present in enormous numbers, they can no
longer produce any injurious effect. In other words,
it has acquired immunity against this particular germ
and its toxin. In fact, one of our newest and most reli-
able tests for the disease consists in a curious " clump-
ing" or paralyzing power over cultures of the Bacillus
typhosus, shown by a drop of the patient's blood, even
as early as the seventh or eighth day of the illness.
And, while it is an immensely difficult and compli-
cated subject, we are justified in saying that this im-
munity is not merely a substance formed in the body,
the stock of which will shortly become exhausted, but
a faculty acquired by the body-cells, which they will
retain, like other results of education, for years, and
even for life. When once the body has learned the
wrestling trick of throwing and vanquishing a particu-

TYPHOID FEVER 219

lar germ or bacillus, it no longer has much to dread
from that germ. This is why the same individual is
seldom attacked the second time by scarlet fever,
measles, typhoid, and smallpox.

While, however, the individual may be entirely im-
mune to the germs of a given disease, he may carry
them in his body in enormous numbers, and infect
others while escaping himself.

This is peculiarly true of typhoid, and we are begin-
ning to extend our sanitary care over recovered patients,
not merely to the end of acute illness, but for the period
of at least a month after they have apparently recov-
ered. Several most disquieting cases are on record of
so-called "typhoid carriers," or individuals who,
having recovered from the disease itself, carried and
spread the infection wherever they went for months
and even years afterward. This, however, is probably
a rare state of affairs, though a recent German health
bulletin reports the discovery of some twenty cases
during the past year. The lair of the bacilli is believed
to be the gall-bladder.

As to treatment, it may be broadly stated that all
authorities and schools are for once practically
agreed : —

First, that we have no known specific drug for the
cure of the disease.

Second, that we are content to take a leaf out of na-
ture's book, and follow — so to speak — her instinctive
methods: first of all, by putting the patient to bed the
moment that a reasonable suspicion of the disease is
formed ; this conserves his strength, and greatly dimin-

220 PREVENTABLE DISEASES

ishes the danger of serious complications; cases of
" walking typhoid " have among the highest death-rates ;
second, by meeting the great instinctive symptom of fe-
ver patients since the world began, thirst, encouraging
the patient to drink large quantities of water, taking
care, of course, that the water is pure and sterile. The
days when we kept fever patients wrapped up to their
necks in woolen blankets in hot, stuffy rooms, and rigor-
ously limited the amount of water that they drank - — in
other words, fought against nature in the treatment of
disease — have passed. A typhoid-fever patient now is
not only given all he wants to drink, but encouraged
to take more, and some authorities recommend an
intake of at least three or four quarts, and, better, six
and eight quarts a day. This internal bath helps not
only to allay the temperature, but to make good the
enormous loss by perspiration from the fevered skin,
and to flush the toxins out of the body.

Third, by liberal and regular feeding chiefly with
some liquid or semi-liquid food, of which milk is the
commonest form. The old attitude of mind represented
by the proverb, "Feed a cold and starve a fever," has
completely disappeared. One of the fathers of modern
medicine asked on his death-bed, thirty years ago, that
his epitaph should be, " He fed fevers."

Fourth. We respond to the other great thirst of
fever patients, for coolness, by sponge baths and tub
baths, whenever the temperature rises above a certain
degree.

Simple as these methods sound, they are extremely
troublesome to put into execution, and require the

TYPHOID FEVER 221

greatest skill and judgment in their carrying out. But
intelligent persistence in the careful elaboration of
these methods of nature has resulted in already cutting
the death-rate in two, — from fifteen or twenty per
cent to less than ten per cent, — and where the full
rigor of the tub bath is carried out it has been brought
down to as low as five per cent.

Meanwhile the bacteriologists are steadily at work
on a vaccine or antitoxin. Wright, of the English Army
Medical Staff, has already secured a serum, which has
given remarkable results in protecting regiments sent
out to South Africa and, other infected regions. Chante-
messe has imported some six hundred successive cases
treated with an antitoxin, whose mortality was only
about a third of the ordinary hospital rate, and the
future is full of promise.

CHAPTER X

DIPHTHERIA

THAT was a dark and stern saying, " Without the
shedding of blood there is no remission,'* and, like
all the words of the oracles, of limited application. But
it proves true in some unexpected places outside of the
realm of theology. Was there something prophetic in
the legend that it was only by the sprinkling of the
blood of the Paschal Lamb above the doorway that
the plague of the firstborn could be stayed ? To-day
the guinea-pig is our burnt offering against a plague
as deadly as any sent into Egypt.

Scarcely more than a decade ago, as the mother sat
by the cradle of her firstborn, musing over his future,
one moment fearfully reckoning the gauntlet of risks
that his tiny life had to run, and the next building rosy
air-castles of his happiness and success, there was one
shadow that ever fell black and sinister across his tiny
horoscope. Certain risks there were which were almost
inevitable, — initiation ceremonies into life, mild expia-
tions to be paid to the gods of the modern underworld,
the diseases of infancy and of childhood. Most of these
could be passed over with little more than a temporary
wrinkle to break her smile. They were so trivial, so
comparatively harmless : measles, a mere reddening of
the eyelids and peppering of the throat, with a head-
ache and purplish rash, dangerous only if neglected;

DIPHTHERIA 223

chicken-pox, a child's-play at disease; scarlatina, a
little more serious, but still with the chances of twenty
to one in favor of recovery; diphtheria — ah! that drove
the smile from her face and the blood from her lips.
Not quite so common, not so inevitable as a prospect,
but, as a possibility, full of terror, once its poison had
passed the gates of the body fortress. The fight be-
tween the Angel of Life and the Angel of Death was
waged on almost equal terms, with none daring to say
which would be the victor, and none able to lift a hand
with any certainty to aid.

Nor was the doctor, in much happier plight. Even
when the life at stake was not one of his own loved ones,
— though from the deadly contagiousness of the disease
it sadly often was (I have known more doctors made
childless by diphtheria than by any other disease ex-
cept tuberculosis) , — he faced his cases by the hun-
dred instead of by twos and threes. The feeling of
helplessness, the sense of foreboding, with which we
faced every case was something appalling. Few of us
who have been in practice twenty years or more, or even
fifteen, will ever forget the shock of dismay which ran
through us whenever a case to which we had been sum-
moned revealed itself to be diphtheria. Of course,
there was a fighting chance, and we made the most of
it; for in the milder epidemics only ten to twenty per
cent of the patients died, and even in the severest a
third of them recovered. But what " turned our liver
to water" — as the graphic Oriental phrase has it —
was the knowledge which, like Banquo's ghost, would
not down, that while many cases would recover of

224 PREVENTABLE DISEASES

themselves, and in many border-line ones our skill
would turn the balance in favor of recovery, yet if the
disease happened to take a certain sadly familiar, viru-
lent form we could do little more to stay its fatal course
than we could to stop an avalanche, and we never knew
when a particular epidemic or a particular case would
take that turn. "Black" diphtheria was as deadly as
the Black Death of the Middle Ages.

The disease which caused all this terror and havoc
is of singular character and history. It is not a modern
invention or development, as is sometimes believed, for
descriptions are on record of so-called " Egyptian ulcer
of the throat" in the earliest centuries of our era; and
it would appear to have been recognized by both Hip-
pocrates and Galen. Epidemics of it also occurred in
the Middle Ages; and, coming to more recent times,
one of the many enemies which the Pilgrim Fathers
had to fight was a series of epidemics of this "black
sore throat," of particularly malignant character, in the
seventeenth century. Nevertheless, it does not seem to
have become sufficiently common to be distinctly
recognized until it was named as a definite disease, and
given the title which it now bears, by the celebrated
French physician, Bretonneau, about eighty years ago.
Since then it has become either more widely recognized
or steadily more prevalent, and it is the general opinion
of pathologists that the disease, up to some thirty or
forty years ago, was steadily increasing, both in fre-
quency and in severity.

So that we have not to deal with a disease which, like
the other so-called diseases of childhood, has gradually

DIPHTHERIA 225

become milder and milder by a sort of racial vaccina-
tion, with survival of the less susceptible, but one which
is still full of virulence and of possibilities of future
danger.

Unlike the other diseases of childhood, also, one
attack confers no positive immunity for the future,
although it greatly diminishes the probabilities; and,
further, while adults do not readily or frequently catch
the disease, yet when they do the results are apt to be
exceedingly serious. Indeed, we have practically come
to the conclusion that one of the main reasons why
adults do not develop diphtheria so frequently as chil-
dren, is that they are not brought into such close and
intimate contact with other children, nor are they in
the habit of promptly and indiscriminately hugging
and kissing every one who happens to attract their
transient affection, and they have outgrown that cheer-
ful spirit of comradeship which leads to the sharing of
candy in alternate sucks, and the passing on of slate-
pencils, chewing-gum, and other objets d'art from hand
to hand, and from mouth to mouth. Statistics show
that of nurses employed in diphtheria wards, before the
cause or the exact method of contagion was clearly un-
derstood, nearly thirty per cent developed the disease;
and even with every modern precaution there are few
diseases which doctors more frequently catch from
their patients than diphtheria. It is a significant fact
that the risk of developing diphtheria is greatest
precisely at the ages when there is not the slightest
scruple about putting everything that may be picked
up into the mouth, — namely, from the second to the

226 PREVENTABLE DISEASES

fifth year, — and diminishes steadily as habits of clean-
liness and caution in this regard are developed, even
though no immunity may have been gained by a mild
or slight attack of the disease. The tendency to dis-
courage and forbid the indiscriminate kissing of chil-
dren, and the crusade against the uses of the mouth as a
pencil-holder, pincushion, and general receptacle for
odds and ends, would be thoroughly justified by the
risks from diphtheria alone, to say nothing of tuber-
culosis and other infections.

In addition to being almost the only common disease
of childhood which is not mild and becoming milder,
diphtheria is unique in another respect, and that is its
point of attack. Just as tuberculosis seizes its victims
by the lungs, and typhoid fever by the bowels, diph-
theria — like the weasel — grips at the throat. Its
bacilli, entering through the mouth and gaining a foot-
hold first upon the tonsils, the palate, or back of the
throat (pharynx), multiply and spread until they
swarm down into the larynx and windpipe, where their
millions, swarming in the mesh of fibrin poured out by
the outraged blood-vessels, grow into the deadly false
membrane which fills the air-tube and slowly strangles
its victim to death.

The horrors of a death like that can never fade from
the memory of one who has once seen it, and will out-
weigh the lives of a thousand guinea-pigs. No wonder
there was such a widespread and peculiar horror of the
disease, as of some ghostly thug or strangler.

But not all of the dread of diphtheria went under its
own name. Most of us can still remember when the

DIPHTHERIA 227

commonest occupant of the nursery shelf was the bottle
of ipecac or soothing-syrup as a specific against croup.
The thing that most often kept the mother or nurse of
young children awake and listening through the night-
watches was the sound of a cough, and the anxious
waiting to hear whether the next explosion had a
"croupy" or brassy sound. It was, of course, early
recognized that there were two kinds of croup, the so-
called "spasmodic" and the "membranous," the for-
mer comparatively common and correspondingly
harmless, the latter one of the deadliest of known dis-
eases. The fear that made the mother's heart leap into
her mouth as she heard the ringing croup-cough was
lest it might be membranous, or, if spasmodic, might
turn into the deadly form later. To-day most young
mothers hardly know the name of wine of ipecac or
alum, and the coughs of young children awaken little
more terror than a similar sound in an adult. Croup
has almost ceased to be one of the bogies of the nursery.
And why ? Because membranous croup has been dis-
covered to be diphtheria, and children will not develop
diphtheria unless they have been exposed to the con-
tagion, while, if they should be, we have a remedy
against it.

He was a bold man who first ventured to announce
this, and for years the battle raged hotly. It was early
admitted that certain cases of so-called membranous
croup in children occurred after or while other members
of the family or household had diphtheria ; and for a
time the opposing camps used such words as " sporadic"
or scattered croup, which was supposed to come of

228 PREVENTABLE DISEASES

itself, and "epidemic'* or contagious croup, which was
diphtheria. Now, however, these distinctions are swept
away, and boards of health require isolation and quar-
antine against croup exactly as against any other form
of diphtheria.

Cases of fatal croup still occasionally occur which
cannot be directly traced to other cases of diphtheria,
but the vast majority of them are clearly traceable to
infection, usually from some case in another child,
which was so mild that it was not recognized as diph-
theria until the baby became "croupy" and search
was made through the family throats for the bacilli.

For years we were in doubt as to the cause of diph-
theria. Half a dozen different theories were advanced,
bad sewerage, foul air, overcrowding; but it was not
until shortly after the Columbus-like discovery, by
Robert Koch, of the new continent of bacteriology, that
the germ which caused it was arrested, tried, and found
guilty, and our real knowledge of and control over the
disease began. This was in 1883, when the bacteriolo-
gist Klebs discovered the organism, followed a few
months later (in 1884) by Loffler, who made valuable
additions to our knowledge of it; so that it has ever
since been known as the Klebs-Loffler bacillus. This
put us upon solid ground, and our progress was both
sure and rapid : in ten years our knowledge of the causa-
tion, the method of spread, the mode of assault upon
the body-fortress, and last, but not least, the cure,
stood out clear cut as a die, a model and a prophecy
of what may be hoped for in most other contagious
diseases.

DIPHTHERIA 229

Great as is the credit to which bacteriologists are
entitled for this splendid piece of scientific progress,
there was another co-laborer, a silent partner, with
them in all this triumph, an unsung hero and martyr
of science who deserves his meed of praise — the tiny
guinea-pig. He well deserves his niche in the temple of
fame ; and as other races and ages have worshiped the
elephant, the snake, and the sacred cow, so this age
should erect its temples to the guinea-pig. From one
of the most trifling and unimportant, — kept merely
as a pet and curiosity by the small boys of all ages, —
he has become, after the horse, the cow, the pig, and
the sheep, easily our most useful and important domes-
tic animal. It may be urged that he deserves no credit,
since his sacrifice — though of inestimable value —
was entirely involuntary on his own part; but this
should only make us the more deeply bound to acknow-
ledge our obligation to him.

By a stern necessity of fate, which no one regrets
more keenly than the laboratory workers themselves,
the guinea-pig has had to be used as a stepping-stone
for every inch of this progress. Upon it were conducted
every one of the experiments whose results widened
our knowledge, until we found that this bacillus and
no other would cause diphtheria ; that instead of get-
ting, like many other disease-germs, into the blood, it
chiefly limited itself to growing and multiplying upon a
comparatively small patch of the Jpody-surface, most
commonly of the throat; that most of its serious and
fatal results upon the body were produced, not by the
entrance of the germs themselves into the blood, but

230 PREVENTABLE DISEASES

by the absorption of the toxins or poisons produced
by them on the moist surface of the throat, just as the
yeast plant will produce alcohol in grape juice or sweet
cider.

Here was a most important clew. It was not neces-
sary to fight the germs themselves in every part of the
body, but merely to introduce some ferment or chemical
substance which would have the power of neutralizing
their poison. Instantly attention was turned in this
direction, and it was quickly found that if a guinea-pig
were injected with a very small dose of the diphtheria
toxin and allowed to recover, he would then be able
to throw off a still larger dose, until finally, after a
number of weeks, he could be given a dose which would
have promptly killed him in the beginning of the experi-
ments, but which he now readily resisted and recovered
from. Evidently some substance was produced in his
blood which was a natural antidote for the toxin, and
a little further search quickly resulted in discovering
and filtering out of his body the now famous antitoxin.
A dose of this injected into another guinea-pig suffering
from diphtheria would promptly save its life.

Could this antitoxin be obtained in sufficient amounts
to protect the body of a human being ? The guinea-pig
was so tiny and the process of antitoxin-forming so
slow, that we naturally turned to larger animals as a
possible source, and here it was quickly found that not
only would the goat and the horse develop this antidote
substance very quickly and in large amounts, but that
a certain amount of it, or a substance acting as an anti-
toxin, was present in their blood to begin with. Of the

DIPHTHERIA 231

two, the horse was found to give both the stronger anti-
toxin and the larger amounts of it, so that he is now
exclusively used for its production.

After his resisting power had been raised to the
highest possible pitch by successive injections of in-
creasing doses of the toxin, and his serum (the watery
part of the blood which contains the healing body)
had been used hundreds and hundreds of times to save
the lives of diphtheria-stricken guinea-pigs, and had
been shown over and over again to be not merely magi-
cally curative but absolutely harmless, it was tried with
fear and trembling upon a gasping, struggling, suffo-
cating child, as a last possible resort to save a life other-
wise hopelessly doomed. Who could tell whether the
"heal-serum," as the Germans call it, would act in a
human being as it had upon all the other animals?
In agonies of suspense, vibrating between hope and
dread, doctors and parents hung over the couch. What
was their delight, within a few hours, to see the muscles
of the little one begin to relax, the fatal blueness of its
lips to diminish, and its breathing become easier. In
a few hours more the color had returned to the ashen
face and it was breathing quietly. Then it began to
cough and to bring up pieces of the loosened membrane
that had been strangling it. Another dose was eagerly
injected, and within twenty-four hours the child was
sleeping peacefully — out of danger. And the most
priceless and marvelous life-saving weapon of the cen-
tury had been placed in the hand of the physician.

Of course there were many disappointments and
failures in the earlier cases. Our first antitoxins were

232 PREVENTABLE DISEASES

too weak and too variable. We were afraid to use them
in sufficient doses. Often their injection would not be
consented to until the case had become hopeless. But
courage and industry have conquered these difficulties
one after another, until now the fact that the prompt
and intelligent use of antitoxin will effect a cure of from
ninety to ninety-five per cent of all cases of diphtheria
is as thoroughly established as any other fact in medi-
cine. The mass of figures from all parts of the world
in support of its value has become so overwhelming
that it is neither possible nor necessary to specify them
in detail. The series of Bayeaux, covering two hundred
and thirty thousand cases of diphtheria, chiefly from
hospitals and hence of the severest type, showing that
the death-rate had been reduced from over fifty-five per
cent to below sixteen per cent already, and that this
decrease was still continuing, will serve as a fair sample.
Three-quarters of even this sixteen per cent mortality
is due to delay in the administration of the antitoxin,
as is vividly shown in thousands of cases now on record,
classified according to the day of the disease on which
the antitoxin was given, of which MacCombie's "Re-
port of the London Asylums Board" is a fair type.
Of one hundred and eighty-seven cases treated the first
day of the disease, none died ; of eleven hundred and
eighty-six injected on the second day of the disease,
four and a half per cent died ; of twelve hundred and
thirty-three not treated until the third day of the dis-
ease, eleven per cent died ; of nine hundred and sixty-
three cases escaping treatment until the fourth day,
seventeen per cent died ; while of twelve hundred and

DIPHTHERIA 233

sixty not seen until the fifth day, twenty per cent died.
In other words, the chances for cure by the anti-
toxin are in precise proportion to the earliness with
which it is administered, and are over four times as
great during the first two days of the disease as they
are after the fourth day. One "stick" in time saves
five.

This brings us sharply to the fact that the most im-
portant factor in the cure of diphtheria, just as in the
case of tuberculosis, is early recognition. How can this
be secured ? Here again the bacteriologist comes to
our relief, and we needed his aid badly. The symptoms
of a mild case of diphtheria for the first two, or even
three, days are very much like those of an ordinary sore
throat. As a rule, even the well-known membrane does
not appear in sufficient amounts to be recognizable
by the naked eye until the middle of the second, or
sometimes even of the third, day. By any ordinary
means, then, of diagnosis, we would often be in doubt
as to whether a case were diphtheria or not, until it was
both well advanced and had had time to infect other
members of the family. With the help of the labora-
tory, however, we have a prompt, positive, and simple
method of deciding at the very earliest stage. We
merely take a sterilized swab of cotton on the end of a
wire, rub it gently over the surface of the throat and
tonsils, restore it to its glass tube, smearing it over
the surface of some solidified blood-serum placed at the
bottom of the tube, close the tube and send it to the
nearest laboratory. The culture is put into an incubator
at body heat, the germs sown upon the surface of the

234 PREVENTABLE DISEASES

\
blood-serum grow and multiply, and in twelve hours a

positive diagnosis can be made by examining this
growth with a microscope. Often, just smearing the
mucus swabbed out of the throat over the surface of a
glass slide, staining this smear, and putting it under a
microscope, will enable us to decide within an hour.
These tubes are now provided by all progressive city
boards of health, and can be had free of charge at
depots scattered all over the city, for use in any doubtful
case, within half an hour. Twelve hours later a free
report can be had from the public laboratory. If every
case of suspicious sore throat in a child were promptly
swabbed out, and a smear from the swab examined at
a laboratory, it would not be long before diphtheria
would be practically exterminated, as smallpox has
been by vaccination, and this is what we are working
toward and looking forward to.

Our knowledge of the precise cause of diphtheria,
the Klebs-Loffler bacillus, has furnished us not only
with the cure, but also with the means of preventing
its spread. While under certain circumstances, par-
ticularly the presence of moisture and the absence of
light, this germ may live and remain virulent for weeks
outside of the body, careful study of its behavior under
all sorts of conditions has revealed the consoling fact
that its vitality outside of the human or some other
living animal body is low ; so that it is relatively seldom
carried from one case to another by articles of clothing,
books, or toys, and comparatively seldom even through
a third party, except where the latter has come into
very close contact with the disease, like a doctor, a

DIPHTHERIA 235

nurse, or a mother, or — without disrespect to the pre-
ceding — a pet cat or dog.

More than this, the bacillus must chiefly be trans-
mitted in the moist condition and does not float in the
air at all, clinging only to such objects as may have
become smeared with the mucus from the child's
throat, as by being coughed or sneezed upon. As with
most of our germ-enemies, sunlight is its deadliest foe,
and it will not live more than two or three days exposed
to sunshine. So the principal danger against which we
must be on our guard is that of direct personal contact,
as in kissing, in the use of spoons or cups in common,
in the interchange of candy or pencils, or through hav-
ing the hands or clothing sprayed by a cough or a
sneeze.

The bacillus comparatively seldom even gets on the
floor or walls of a room where reasonable precautions
against coughing and spitting have been taken; but
it is, of course, advisable thoroughly to disinfect and
sterilize the room of a patient and all its contents with
corrosive sublimate and formalin, as a number of cases
are on record in which the disease has been carried
through books and articles of clothing which had been
kept in damp, dark places for several months. The
chief method of spread is through unrecognized mild
cases of the disease, especially of the nasal form. For
this reason boards of health now always insist upon
smears being made from the throats and noses of every
other child in the family or house where a case of diph-
theria is recognized. No small percentages of these are
found to be suffering from a mild form of the disease,

236 PREVENTABLE DISEASES

so slight as to cause them little inconvenience and no
interference with their attending school. Unfortu-
nately, a case caught from one of these mild forms may
develop into the severest laryngeal type. If a child is
running freely at the nose, keep it at home or keep your
own child away from it. A profuse nasal discharge is
generally infectious, in the case of influenza or other
"colds," if not of diphtheria.

This also emphasizes the necessity for a thorough
and expert medical inspection of school-children, to
prevent these mild cases from spreading disease and
death to their fellows. By an intelligent combination
of the two methods, home examination of every in-
fected family and strict school inspection, there is little
difficulty in stamping out promptly a beginning infec-
tion before it has had time to reach the proportions
of an epidemic.

One other step makes assurance doubly sure, and
that is the prompt injection of all other children and
young adults living in the family, where there is a case
of diphtheria, with small doses of the antitoxin for pre-
ventive purposes. Its value in this respect has been only
secondary to its use as a cure. There are now thousands
of cases on record of children who had been exposed
to diphtheria or were in hospitals where they were in
danger of becoming exposed to it, with the delightful
result that only a very small per cent of those so pro-
tected developed the disease, and of these not a single
one died ! This protective vaccination, however, cannot
be used on a large scale, as in the case of smallpox,
for the reason that the period of protection is a com-

DIPHTHERIA 237

paratively short one, probably not exceeding two or
three weeks.

Suppose that, in spite of all our precautions, the dis-
ease has gained a foothold in the throat, what will be
its course ? This will depend, first of all, upon whether
the invading germs have lodged in their commonest
point of attack, the tonsils, palate, and upper throat,
or have penetrated down the air-passages into the lar-
ynx or voice-organ. In the former, which is far the
commoner case, their presence will cause an irritation
of the surface cells which brings out the leucocyte cav-
alry of the body to the, defense, together with squads
of the serum or watery fluid of the blood containing
fibrin. These, together with the surface-cells, are
rapidly coagulated and killed by the deadly toxin ; and
their remains form a coating upon the surface, which
at first is scarcely perceptible, a thin, grayish film,
but which in the course of twenty-four to forty-eight
hours rapidly thickens to the well-known and dreaded
false membrane. Before, however, it has thickened in
more than, occasional spots or patches, the toxin has
begun to penetrate into the blood, and the little patient
will complain of headache, feverishness, and backache,
often — indeed, usually — before any very marked
soreness in the throat is complained of. Roughly
speaking, attacks of sore throat, which begin first of all
with well-marked soreness and pain in the throat, fol-
lowed later by headache, backache, and fever, are not
very likely to be diphtheria. The bacilli multiply and
increase in their deadly mat on the surface of the throat,
larger and larger amounts,of the poison are poured into

238 PREVENTABLE DISEASES

the blood, the temperature goes up, the headache
increases, the child often begins to vomit, and becomes
seriously ill. The glands of the neck, in their efforts
to arrest and neutralize the poison, become swollen
and sore to the touch, the breath becomes foul from
the breaking down of the membrane in the throat, the
pulse becomes rapid and weak from the effect of the
poison upon the heart, and the dreaded picture of
the disease rapidly develops.

This process in from sixty to eighty per cent of cases
will continue for from three to seven days, when a check
will come and the condition will gradually improve.
This is a sign that the defensive tissues of the body
have succeeded in rallying their forces against the at-
tack, and have poured out sufficient amounts of their
natural antitoxin to neutralize the poisons poured in
by the invaders. The membrane begins to break down
and peel off the throat, the temperature goes down, the
headache disappears, the swelling in the glands of the
neck may either subside or go on to suppuration and
rupture, but within another week the child is fairly
on the way to recovery.

Should the invaders, however, have secured a foot-
hold in the larynx, then the picture is sadly different.
The child may have even less headache, temperature,
and general sense of illness; but he begins to cough,
and the cough has a ringing, brassy sound. Within
forty-eight, or even twenty-four, hours he begins to
have difficulty in respiration. This rapidly increases
as the delicate tissues of the larynx swell under the
attack of the poison, and the very membrane which is

DIPHTHERIA 239

created in an attempt at defense becomes the body's
own undoing by increasing the blocking of the air-pas-
sages. The difficulty of breathing becomes greater and
greater, until the little victim tosses continually from
side to side in one constant, agonizing struggle for
breath. After a time, however, the accumulation of
carbon dioxide in the blood produces its merciful nar-
cotic effect, and the struggles cease. The breathing be-
comes shallower and shallower, the lips become first
blue, then ashy pale, and the little torch of life goes
out with a flicker. This was what we had to expect,
in spite of our utmost effort, in from seventy to ninety
per cent of these laryngeal cases, before the days of the
blessed antitoxin. Now we actually reverse these per-
centages, prevent the vast majority of cases from de-
veloping serious laryngeal symptoms at all, and save
from seventy to eighty per cent of those who do.

Our only resource in this form of the disease used
to be by mechanical or surgical means, opening the
windpipe below the level of the obstruction and insert-
ing a curved silver tube — the so-called tracheotomy
operation ; or later, and less heroic, by pushing forcibly
down into the larynx, and through and past the obstruc-
tion at the vocal cords, a small metal tube through
which the child could manage to breathe. This was
known as intubation. But these were both distressing
and painful methods, and, what was far worse, piti-
fully broken reeds to depend upon. In spite of the
utmost skill of our surgeons, from fifty to eighty per
cent of cases that were tracheotomized, and from forty
to sixty per cent of those that were intubated, died.

240 PREVENTABLE DISEASES

In many cases they were enabled to breathe, their
attacks of suffocation were relieved — but still they
died.

This leads us to the most important single fact about
the course of the disease, and that is that the chief
source of danger is not so much from direct suffocation
as from general collapse, and particularly failure of
the heart.

This has given us two other data of great importance
and value, namely, that while the immediate and great-
est peril is over when the membrane has become loos-
ened and the temperature has begun to subside, in
both ordinary throat and in laryngeal forms of the
disease, the patient is by no means out of danger.
While the antitoxins poured out by his body have com-
pletely defeated the invading toxins in the open field of
the blood, yet almost every tissue of the body is still
saturated with these latter and has often been seriously
damaged by them before their course was checked.
For instance, nearly two-thirds of our diphtheria cases,
which are properly examined, will show albumin in the
urine, showing that the kidney-cells have been attacked
and poisoned by the toxin. This may go on to a fatal
attack of uremia; but fortunately, not commonly, far
less so than in scarlet fever. The kidneys usually
recover completely, but this may take weeks and
months. Again, many cases of diphtheria will show
a weak and rapid pulse, which will persist for weeks
after the patient has apparently recovered ; and if the
little ones are allowed to sit up too soon, or to indulge
in any sudden movements or muscular strains, this

DIPHTHERIA 241

weak and rapid pulse will suddenly change into an
attack of heart failure and, possibly, fatal collapse.
This, again, illustrates the saturation of the poison,
as these effects are now known to be due in part to a
direct poisoning of the muscle of the heart itself, and
later to serious damage done to the nerves controlling
the heart, chiefly the pneumo-gastric. Moral: Keep
the little patient in bed for at least two weeks or, better,
three. He will have to spend a month or more in quar-
antine, anyway.

Last of all, and by no means least interesting, are
the effects which are produced upon the nervous system.
One day, while the child is recovering, and is possibly
beginning to sit up in bed, a glass of milk is handed to
him. The little one drinks it eagerly and attempts to
swallow, but suddenly it chokes, half strangles, and
back comes the milk, pouring out through the nostrils.
Paralysis of the soft palate has occurred from poison-
ing of the nerves controlling it, caused by direct pene-
tration of the toxin. Sometimes the muscles of the
eye become paralyzed and the little one squints, or
can no longer see to read.

Fortunately, most of these alarming results go only
to a certain degree, and then gradually fade away and
disappear ; but this may take months or even longer.
In a certain number, however, the nerves of respira-
tion, or those controlling the heart-beat, become affected,
and the patient dies suddenly from heart failure.

This strange after-effect upon the nervous system,
which was first clearly noticed in diphtheria and
syphilis, has now been found to occur in lesser

242 PREVENTABLE DISEASES

degree in a large number of our infectious diseases, so
that many of our most serious paralyses and other dis-
eases of the nervous system are now traceable to such
causes.

These effects of the diphtheria toxin are also of inter-
est for a somewhat unexpected reason, since it has been
claimed that they are effects of the antitoxin, by those
who are opposed to its use. Every one of them was well
recognized as a possible result of diphtheria long before
the antitoxin was discovered, and every one of them
can be readily produced by injections of diphtheria
bacilli or their toxin into animals.

It is quite possibly true that there are more cases
of nerve-poisoning (neuritis) and of paralysis following
diphtheria than there were before the use of antitoxin,
but that is for the simple and sufficient reason that there
are more children left alive to display them ! And be-
tween a child with a temporary squint and a dead child
few mothers would hesitate long in their choice.

CHAPTER XI

THE HERODS OF OUR DAY I SCARLET FEVER, MEASLES,
AND WHOOPING-COUGH

WHY is a disease a disease of childhood ? First
and fundamentally, because that is the earliest
period at which a human being can have it. But the
problem goes deeper than this. There is no more inter-
esting and important group of diseases in the whole
realm of pathology than those which we calmly dub
"the diseases of childhood," and thereby dismiss
to the limbo of unavoidable accidents and discomforts,
like flies, mosquitoes, and stubbed toes, which are best
treated with a shrug of the shoulders and such stoic
philosophy as we can muster. They are interesting,
because the moment we begin to study them intelli-
gently we stumble upon some of the profoundest and
most far-reaching problems of resistance to disease;
important, because, trifling as we regard them, and
indeed largely just because we so regard them, they
kill, or handicap for life, more children in civilized com-
munities than the most deadly pestilence. Measles, for
instance, according to the last United States census,
causes yearly nearly thirteen thousand deaths, while
smallpox causes so few that it is not listed among the
important causes of death. Scarlet fever causes sixty-
three hundred and thirty-three deaths, as compared

244 PREVENTABLE DISEASES

with barely five thousand from appendicitis and the
same number from rheumatism. Whooping-cough
causes ninety-nine hundred and fifty-eight deaths, more
than double the mortality from diabetes and nearly
equal to that of malarial fever.

In medicine, as in war, the gravest and deadliest
mistake that you can make is to despise your enemy.
These trivial disorders, these trifling ailments, which
every one takes as a matter of course, and expects to go
through with, like teething, tight shoes, and learning
to smoke, sweep away every year in these United States
the lives of from forty to fifty thousand children, reach-
ing the bad eminence of fifth upon our mortality lists,
only consumption, pneumonia, heart disease, and
diarrhceal diseases ranking above them. Of course,
it is obvious that these diseases outrank many other
more serious ones among the " captains of the men of
death," largely upon the familiar principle of the old
riddle, whereby the white sheep eat more grass than
the black, " because there are more of them."

While only a relatively small percentage of us ever
have the bad luck to be attacked by typhoid fever,
rheumatism, or appendicitis, to say nothing of cholera
and smallpox, the vast majority of us have gone
through two or more of these diseases of childhood;
so that, though the death-rate of each and all of them
is low, yet the number of cases is so enormous that the
absolute total mounts high. But the pity and, at the
same time, the practical importance of this heavy death-
roll is that at least two-thirds of it is absolutely prevent-
able, and by the exercise of only a very moderate

THE HERODS OF OUR DAY 245

amount of intelligence and vigilance. It is, of course,
obvious that in a group of diseases which numbers its
victims literally by the million every year there will
inevitably occur a certain minute percentage of fatal
results due to what might be termed unavoidable
causes, like a badly nourished condition of the child
attacked, unusual circumstances preventing proper
shelter or nursing, or an exceptional virulence of
the disease, such as will occur in two or three cases
of every thousand in even the most trifling infectious
malady. But even after making liberal allowance for
what might be termed the unavoidable fatalities, at
least two-thirds, and more probably nine-tenths, of the
deaths from children's diseases might be prevented
upon two grounds : —

First, that they are contagious and absolutely de-
pendent upon a living germ, whose spread can be pre-
vented ; and secondly, and practically even more im-
portant, that more than half the deaths from them are
due, not to the disease itself, but to complications
occurring during the period of recovery, caused, for
the most part, by gross carelessness on the part of the
mother or nurse. A large majority, for instance, of
the nearly thirteen thousand deaths attributed to
measles are due to bronchitis, caught by letting the
child go out-of-doors too soon after recovery, which
means, of course, either a chill falling upon the irritated
and weakened bronchial mucous membrane, or an
infection by one of the score of disease-germs, such as
those of influenza, pneumonia, bronchitis, and even
tuberculosis, which are continually lying in wait for just

246 PREVENTABLE DISEASES

such an emergency as this — just such a weakening of
the vital resistance.

It is a sadly familiar statement in the history of fatal
cases of tuberculosis that the trouble " began with an
attack of measles," or whooping-cough, or a bad cold,
and was mistaken for a mere "hanging on" of one of
these milder maladies until it had gained a foothold that
there was no dislodging. As breakers of the wall of the
hollow square of the body-cells, drawn up to resist the
cavalry charges of tuberculosis, pneumonia, and rheu-
matism, few can be compared in deadliness with the
diseases of childhood and " common colds."

Further, while all of them except scarlet fever have
a mortality so low that it might almost be described as
what the French delicately term une quantite negli-
geable, yet a surprisingly large number of the survivors
do not escape scot-free, but bear scars which they may
carry to their graves, or which may even carry them
to that bourne later. Again, the actual percentage of the
survivors who are marked in this fashion is small, but
such milliards of children are attacked every year that,
on the old familiar principle, " if you throw plenty of
mud some of it will stick," quite a serious number are
more or less handicapped by these remainders. For
instance, quite a noticeable percentage of cases of
chronic eye troubles, particularly of the lids and con-
junctiva, such as "granulated" lids, styes, ulcers of the
cornea, date from an attack of measles or even whoop-
ing-cough. Many cases of nasal catarrh or chronic
throat trouble or bronchitis in children date from the
same source. A large group of chronic discharges from

THE HERODS OF OUR DAY 247

the ear and perforations of the ear-drum are a direct
after-result of scarlet fever; and the frequency with
which this disease causes serious disturbances of the
kidneys is almost a household word. Less definitely
traceable, but even more serious in their entirety, are
the large group of chronic depression of vigor, loss of
appetite, various forms of indigestion and of bowel
trouble, which are left behind after the visitation of
one of these minor pests, particularly among the
children of the poorer classes, who are unable to obtain
the highly nutritious, appetizing, and delicately cooked
foods which are so essential to the full recovery of the
little invalids.

One of the English commissions which was investigat-
ing the alleged physical deterioration of city and town
populations stumbled upon a singularly interesting and
significant fact in this connection, while plotting the
curves of the rate of growth of the children in a given
district in Scotland during a series of years. They were
struck with the fact that children born in certain years
in the same families, neighborhoods, and presumably
the same circumstances, grew more rapidly and had
a lower death-rate than those born in other years ; and
that, on the other hand, children born in other years
fell almost as far below the normal in their rate of
growth. The only factor which they found to coincide
with these differences was that in the years in which
those children who made the slowest growth were born
there had been unusually heavy epidemics of children's
diseases and a high mortality ; while, on the other hand,
those years whose "crop" of children made the best

248 PREVENTABLE DISEASES

growth had been unusually free from such epidemics
and had a correspondingly low mortality, showing
clearly that even the survivors of children's diseases
were not only not benefited, but distinctly handicapped
and set back in their growth by the energy, so to speak,
wasted in resisting the onslaught.

This brings us to an aspect of these diseases which
from both a philosophic and a practical point of
view is most interesting and profoundly significant;
and that is the question with which we opened : Why
is a disease a disease of childhood? The old, primi-
tive view was as guileless and as simple as the age in
which the diseases occurred. They were regarded not
merely by the laity but by grave and reverend physi-
cians of the Dark Ages as a sort of necessary vital
crisis peculiar and appropriate to each particular age
of life, — a sort of sweating out and erupting of
"peccant humors" of the blood, which must be got rid
of or else the individual would not thrive. Incredible as
it may seem, so far was this idea extended, that the
great Arabian physician-philosopher, Rhazes, actually
included smallpox in this group, as the last of the " crises
of growth" which had to appear and have its way in
young manhood or womanhood. Quaint little echoes
of this simple faith still ring in the popular mind, as,
for instance, in the widespread notion about the danger-
ousness of doing anything to check the eruption in
measles and cause it to "strike in." Any mother in
Israel will tell you, the first time you propose a bath
or a wet pack to reduce the temperature in measles, that
if you so much as touch water to the skin of that child

THE HERODS OF OUR DAY 249

it will "drive the rash in" and cause it to die in con-
vulsions. And, of course, one of the commonest of a
physician's memories is the expression of relief from the
mother cr aunt in any of these mild eruptive fevers,
where the skin was well reddened and spotted : " Well,
anyway, doctor, it is a splendid thing to get the rash
so well out !" Until within the last ten or fifteen years
it was no uncommon thing to hear the expression :
" Well, I suppose we might just as well let Willie and
Susie go on to school and get the measles and have done
with it. It seems to be a real mild sort this time."
Of course this view was scientifically shattered two or
more decades ago by odr recognition of the infectious
nature of these diseases, but practically its hold on the
public mind constitutes one of the most serious and
vital obstacles in the way of the health-officer when he
endeavors to attack and break up an epidemic of
measles, whooping-cough, or chicken-pox.

It cannot be too strongly emphasized that, mild and
in their immediate results trifling, as most of these
"little diseases" are, they are genuine members of that
class of pathologic poison-snakes, the germ-infections ;
that when they bite, they bite to kill ; that two to five
times in every hundred they do kill ; that, like all other
infections, they are capable of inflicting serious and
permanent damage upon the great vital organs, the
heart, the kidneys, the liver, and the brain; and that
they are the very jackals of diseases, tracing down and
pointing out the prey to the lions that work in partner-
ship with them. With whatever we may treat measles
and whooping-cough, never treat them with contempt !

S50 PREVENTABLE DISEASES

The next conception of the " whyness " of children's
diseases was that as one star differs from another in
glory, so does one germ differ from another in virulence ;
that the germs of these particular diseases just happened
to be from the beginning unusually mild and at the
same time highly contagious, so that they remained
permanently scattered about throughout the com-
munity, and attacked each successive brood of new-
born children as quickly as they could conveniently
get at them. Being so mild and so comparatively
seldom fatal, little or no alarm was excited by them and
few efforts made to check their spread, so that they
continued to flourish, generation after generation.
Upon this theory the germs of measles, chicken-pox,
whooping-cough, mumps, would be in something like
the same class as the numerous species of bacteria and
other germs that normally inhabit the human mouth,
stomach, and intestines; for the most part, compara-
tively harmless parasites, or what are technically now
known as "symbiotes" (from two Greek words, bios,
"life," and syn, "with"), a sort of little partners or
non-paying boarders, for the most part harmless, but
occasionally capable of making trouble. There are
scores of species of such germs in our food-canals, some
of which may be even slightly helpful in the process
of digestion. Only a very small per cent of the bacilli
of any sort in the world are harmful ; the vast major-
ity are exceedingly helpful.

There is evidently some truth in this view of chil-
dren's diseases, especially so far as the reason for their
steady persistence and undiminished spread is con-

THE HERODS OF OUR DAY 251

c rned, namely, the comparative carelessness and
indifference with which they are regarded and treated.
But some rather striking developments of recent years
have raised grave doubts in our minds as to whether
they were always the mild and inoffensive "house cats"
that they pass for at present. These are the astonishing
and almost incredible developments that occur when
for the first time these mild and harmless " diseaselets "
are introduced to a savage or half-civilized tribe. Like
an Arabian Nights' transformation, our sleepy, purr-
ing, but still able to scratch, "pussy cat" flashes out
as a ravenous man-eating tiger, killing and maiming
right and left. Measles — harmless, tickly, snuffly,
"measly" little measles — kills from thirty to sixty
per cent of whole villages and tribes of Indians and
cripples half the remainder!

My first direct experience with this feature of our
" household pets " was on the Pacific Coast. All the old
settlers told me of a dread pestilence which had pre-
ceded the coming of the main wave of invading civiliza-
tion, sweeping down the Columbia River. Not merely
were whole clans and villages swept out of existence,
but the valley was practically depopulated ; so that,
as one of the old patriarchs grimly remarked, " It made
it a heap easier to settle it up quietly." So swift and so
fatal had been its onslaught that villages would be
found deserted. The canoes were rotting on the river
bank above high-water mark. The curtains of the
lodges were flapped and blown into shreds. The wea-
pons and garments of the dead lay about them, rusting
and rotting. The salmon-nets were still standing in

252 PREVENTABLE DISEASES

the river, worn to tatters and fringes by the current.
Yet, from the best light that I was able to secure upon
it, it appeared to have been nothing more than an
epidemic of the measles, caught from the child of some
pioneer or trapper and spreading like wildfire in the
prairie grass. A little later I had an opportunity to
see personally an epidemic of mumps in a group of
Indians, and I have seldom seen fever patients, ill
of any disease, who were more violently attacked and
apparently more desperately ill than were sturdy young
Indian boys attacked by this trifling malady. Their
temperatures rose to one hundred and five or one hun-
dred and six degrees, they became delirious, their faces
were red and swollen, they ached in every limb, and
the complications that occasionally follow mumps
even in civilized patients were frequent and exceed-
ingly severe. In like mariner, influenza will slay its
hundreds in a tribe of less than a thousand members.
Chicken-pox will become so virulent as to be mistaken
for smallpox. Several of the epidemics of alleged small-
pox that have occurred among Indians and other savage
tribes are now known to have been only measles. At
first, pathologists were inclined to receive these reports
with some degree of skepticism, and to regard them
either as travelers' tales, or as instances of exceptional
and accidental virulence in that particular tribe, the
high death-rate due to bad nursing or horrible methods
of voodoo treatment.

But from all over the world came ringing in the same
story, not merely from scores of travelers, but also
from army surgeons, medical missionaries, and medi-

THE HERODS OF OUR DAY 253

cal explorers, until it has now become a definitely estab-
lished fact that the mild, trifling diseases of infancy,
"colds" and influenzas of civilized races, leap to the
proportions of a deadly pestilence when communicated
to a savage tribe. Whether that tribe be the Eskimo
of the Northern ice-sheet or the Terra del Fuegian
of the Southern, the Hawaiian of the islands of the
Pacific or the Aymaras of the Amazon, all fall like grain
before the scythe under the attack of a malady which
is little more than the proverbial " little 'oliday " of
three days in bed to civilized man. Evidently civilized
man has acquired a degree and kind of immunity that
uncivilized man has not. Either the disease has grown
milder or civilized man tougher with the ages.

The probability is that both of these explanations
are true. These diseases may originally have been
comparatively severe and serious; but as generation
after generation has been submitted to their attack,
those who were most susceptible died or were so crip-
pled as to be seriously handicapped in the race of life
and have left fewer and less vigorous offspring. So
that, by a gradual process of weeding out the more
susceptible, the more resisting survived and became
the resistant civilized races of to-day.

On the other hand, any disease which kills its victim
so quickly that it has not time to make sure of its trans-
mission to another one before his death, will not have
so many chances of survival as will a milder and more
chronic disorder. Hence, the milder and less fatal
strains of germs would stand the better chance of sur-
vival. This, of course, is a very crude outline, but it

254 PREVENTABLE DISEASES

probably represents something of the process by which
almost all known diseases, except a few untamable
hyenas, like the Black Death, the cholera, and small-
pox, have gradually grown milder with civilization.
If we escape the attack of these attenuated diseases
of infancy until fifteen or sixteen years of age, we can
usually defy them afterward; though occasionally an
unusually virulent strain will attack an adult, with
troublesome consequences.

At all events, whatever explanation we may give, the
consoling fact stands out clearly that civilized man is
decidedly more resistant to these pests of civilization
than is any half-civilized race, and there is good reason
to believe that this is a typical instance of his compara-
tive vigor and endurance all along the line.

If this view of the original character and taming of
these diseases be correct, it also accounts for the ex-
traordinary and otherwise inexplicable cases where they
suddenly assume the virulence of cholera, or yellow
fever, and kill within forty-eight or ninety-six hours,
not merely in children but also in adults.

To group these three diseases together simply be-
cause they all happen to occur in children would appear
scarcely a rational principle of classification. Yet,
practically, widely different as they are in their ultimate
results and, probably, in their origin, they have so many
points in common as to their method of spread, pre-
vention, and general treatment, that what is said of one
will with certain modifications apply to all.

I said " probably " of widely different origin, because,
by one of those strange paradoxes which so often con-

THE HERODS OF OUR DAY 255

front us in real life, though the infectiousness and the
method of spread of all these diseases is as familiar as
the alphabet and as firmly settled, the most careful
study and innumerable researches have failed to
identify positively the germ in any one of them. There
are a number of "suspects" against which a great deal
of circumstantial evidence exists: a streptococcus in
scarlet fever, a bacillus in whooping-cough, and a pro-
tozoan in measles; but none of these have been defi-
nitely convicted. The principal reason for our failure
is a very common one in bacteriological research,
whose importance is not generally known, and that is,
that there is not a single species of the lower animals
that is subject to the diseases or can be inoculated with
them. This unfortunate condition is the greatest bar-
rier which can now exist to our discovery of the causa-
tion of any disease. We were absolutely blocked, for in-
stance, by it in smaHpox and syphilis until we discov-
ered that our nearest blood relatives, the ape and the
monkey, are susceptible to them ; and then the Cytoryctes
Variolce and the Treponema pallida were discovered
within comparatively a few months. Some lucky day,
perhaps, we may stumble on the animal or bird which
will take measles, scarlet fever, or whooping-cough,
and then we will soon find out all about them.

But, fortunately, our knowledge of these little dis-
eases, like Mercutio's wound, is "not so deep as a well,
nor so wide as a church door; but 't is enough" for all
practical purposes. The general plan of treatment in all
of them might be roughly summed up as, rest in bed
in a well-ventilated room ; sponge-baths and packs for

256 PREVENTABLE DISEASES

the fever; milk, eggs, bread, and fruit diet, with plenty
of cool water to drink, either plain, or disguised as
lemonade or "fizzy" mixtures; mild local antiseptic
washes for nose and throat, and mild internal antisep-
tics, with laxatives, for the bowels and kidneys. There
is no known drug which is specific in anyone of them,
though their course may be made milder and the patient
more comfortable by the intelligent use of a variety
of remedies, which assist nature in her fight against
the toxin. Not knowing the precise cause, we have as
yet no reliable antitoxin for any.

Now very briefly as to the earmarks of each particu-
lar member of this children's group. It may be said in
advance that the " openings" of all of them (as chess-
players call the first moves) are very much alike. All of
them are apt to begin with a little redness and itching
of the mucous membranes of the nose, the throat, and
the eyes, with consequent snuffliiig and blinking and
complaints of sore throat. These are followed, or in se-
vere, swift cases may be preceded, by flushed cheeks,
complaints of headache or heaviness in the head, fever,
sometimes rising very quickly to from one hundred and
four to one hundred and five degrees, backache, pains
in the limbs, and, in very severe cases, vomiting. In
fact, the symptoms are almost identical with those of an
attack of that commonest of all acute infections, a
bad cold, and probably for the same reason, namely,
that the germs, whatever they may be, attack and
enter the system by way of the nose and throat.

One of the most difficult practical points about the
beginning of this group of diseases is to distinguish

THE HERODS OF OUR DAY 257

them from one another, or from a common cold. The
important thing to remember is that, theoretically im-
portant as it may be to make this distinction, prac-
tically it is n't necessary at all, as they should all be
treated exactly alike in the beginning. The only vital
thing is to recognize that you are dealing with an infec-
tion of some sort, isolate promptly the little patient,
put him to bed, and make your diagnosis later as the
disease develops. Fortunately neither scarlet fever
nor measles usually becomes acutely infectious until
the rash appears, and as neither is particularly danger-
ous to adults, especially to such as have had them
already, a one-room quarantine is sufficient for the first
few days of any of these diseases. We will lose nothing
and gain enormously by adopting this routine plan in
all cases of snuffling noses, sore throats, headache,
and fever in children, for these are the early symptoms
of all their febrile diseases, from colds to diphtheria ; all
alike are infectious and all, even to the mildest, bene-
fited by a few days of rest and seclusion.

After this first general blare of defiance on the part
of the system to the enemy, whoever he may be, the
battle begins to take on its characteristic form accord-
ing to the nature of the invader. We will take first the
campaign of scarlet fever, since this is the swiftest and
first to disclose itself. After the preliminary snuffles and
headache have lasted for a few hours, the temperature
usually begins to rise; and when it does, by leaps and
bounds often reaching one hundred and four or one
hundred and five degrees within twelve hours, the skin
becomes dry and hot, the throat sore, the tongue

258 PREVENTABLE DISEASES

parched, and the little patient drowsy and heavy-eyed.
Within from twenty-four to forty-eight hours a bright
red or pinkish rash appears, first on the neck and chest,
and then rapidly spreading all over the surface of the
body within another twenty-four hours.

Meanwhile the throat becomes sore and swollen,
ranging, according to the severity of the case, from a
slight reddening and swelling to a furious ulcerative
inflammation, with the formation of a thick membrane-
like exudate, which sometimes is so severe as to raise a
suspicion of possible diphtheria. The tongue becomes
red and naked, with the papillae showing light against
a red ground, so as to give rise to what has been known
as "the strawberry tongue." The temperature is
usually high, and the little patient when he drowses
off to sleep is quite apt to become more or less delirious.
In the vast majority of cases, after two to four days of
this, the temperature goes down almost as swiftly as it
came up, the rash begins to fade, the throat gets less
sore, and the rebound toward recovery sets in. About
this time the daily examination of the urine will begin
to show traces of albumin, but this, under strict rest
in bed and careful diet, will usually diminish and ulti-
mately disappear. In the event of a relapse, however,
or setback from any cause, the kidneys may become
violently attacked, and a considerable per cent of the
fatal cases die from suppression of the urine. After
this crisis has occurred, however, in ninety-nine per
cent of all cases it is comparatively plain sailing; the
throat is still sore and troublesome, the skin itches and
tickles, and the eyes smart, but the little patient steadily

THE HERODS OF OUR DAY 259

improves day by day. Anywhere from three to five days
after the break in the fever the skin begins to get rough
and scaly, and gradually peels off, until in some cases
the entire coating of the body is shed, having been
killed, as it were, by the violence of the eruption. These
flakes and scales of the skin are exceedingly contagious, \
and no case should be regarded as fit to be released
from isolation until every particle has been shed and
got rid of. This constitutes one of the most tiresome
and annoying periods of the disease, as complete shed-
ding is seldom finished before two weeks, and some-
times may last from Jhree to five.

However, this long period of contagiousness has been
found to be really a blessing in disguise, inasmuch as
we now know that even more strikingly than in the
other children's diseases it is the period of recovery that
is the period of greatest danger in scarlet fever. Like the
Parthians of Greek history it is most dangerous when
in retreat. Keeping the child at rest for the greater
part of the time, in bed or on a lounge, in a well-
ventilated room, or later on a porch or terrace, for five
weeks from the beginning of the disease, is well worth
all the trouble and inconvenience that it causes, for
the sake of the almost absolute protection it gives
against dangerous and even fatal complications, par-
ticularly of the kidneys, heart, or lungs.

This is a fair description of what might be termed
an average case of the disease. We also have the sadly
familiar type described as the fulminant or, literally,
" lightning-stroke" variety. The child goes down as if
struck by an invisible hand ; vomiting is one of the first

260 PREVENTABLE DISEASES

symptoms ; delirium follows within ten or twelve hours ;
the eruption becomes not merely scarlet but purplish
from hemorrhage under the skin, giving the name of
" black" scarlet fever to this type. The throat becomes
furiously swollen, the urine is absolutely suppressed, the
child goes into convulsions, and dies within forty-eight
hours from the beginning of the attack. Fortunately,
this type is rare, but the important thing to remember
is that it may develop in a child who caught the disease
from one of the mildest of all possible cases! Hence
every case should be treated with the strictest isolation,
as if it were itself of the most malignant type.

Naturally, the mortality of scarlet fever varies ac-
cording to the type. Not only may it assume a malig-
nant form in individual cases, but whole epidemics may
be of this character, with a mortality of from twenty
to thirty per cent. Generally speaking, however, the
death-rate is about one in twelve, ranging from as low
as one in twenty-five to as high as one in five.

As in the case of diphtheria, the greatest danger
and most powerful means of spread of the disease is
through the mild, unrecognized cases, which are sup-
posed to have nothing but a cold and are allowed to
continue in school or play with other children. We
have no antitoxin and no bacteriologic means of
positive diagnosis. But one method will stop the spread
and writhin ten or fifteen years exterminate every one
of these infections — isolate at once every child that
shows symptoms of a cold, sore throat, or feverishness,
both for its own sake and for that of the community !

In measles we have to deal with a much more harm-

THE HERODS OF OUR DAY 261

less and more nearly domesticated "beast of prey,"
but one of a prevalence to correspond. Though prob-
ably (exact data being as yet lacking) not more than
one-third of all individuals are attacked by scarlet
fever, it would be safe to say that not more than one-
third, and possibly not more than one-fifth, of us escape
measles. Hence, though its mortality is scarcely one-
fourth that of scarlet fever, it more than holds its own
in the Herod class, as grimly shown by its total death-
roll of over twelve thousand, compared with only a
little over six thousand to the credit of scarlet fever.

After the preliminary disturbances of snuffles, hot
throat, headache, and feverishness, which it shares with
all the other " little fevers," the first thing to mark off
measles is usually that the itching and running at the
nose and eyes become more prominent, the child begins
to turn its face away from the light because it makes
its eyes smart, and complains not so much of soreness
as of a peppery, burning, itching sensation in its nose
and throat. The tongue is coated, the stomach mildly
upset; the little patient is more uncomfortable and
fretful than seriously ill. This condition drags on,
without apparently getting anywhere, for from two to
four days, during which time it is often very difficult
even for the most experienced physician to say posi-
tively what the sufferer has. But about the fourth day
a rash begins to appear, typically first upon the cheeks
or forehead in the shape of little widely separated dull-
red blotches. These grow larger and deeper in color,
rising in the middle and spreading at their edges, so that
shortly the whole skin becomes puffed and swollen and

262 PREVENTABLE DISEASES

of a mottled, pinkish-purple color. If the child's lower
lip be pulled down, little red spots will be seen scattered
over the lining membrane of the mouth, showing that
the eruption is not confined to the skin. Indeed, these
Koplik's spots (as they are called, after their discoverer)
in the mouth will often appear a day or more before
the eruption upon the skin and give the first clew to the
nature of the disease. These are significant, because
they probably illustrate the process of eruption, or, at
least, irritation, which is taking place, not merely upon
the skin, but also upon the mucous membranes of the
eyes, nose, and throat, the windpipe and the bronchial
tubes, and which is the cause of the burning, running,
and, later, occasional serious inflammatory symptoms
in all these regions.

When you look at the hot, angry-looking, swollen
skin of the little victim of measles, the weeping eyes
and running nose, and remember that this same sort
of process is either going on or is likely to occur all
over his entire lining, so to speak, from lungs to bowels,
you can easily grasp how important it is to keep him
absolutely at rest and protected from every possible
risk in the way of chill, over-exertion, or injudicious
feeding, until the whole process has completely sub-
sided and been forgotten. Neglect of these precautions
is the reason why so many cases of measles, on the least
and most trifling exposure and overstrain during the
two or three weeks following the disease, will blaze up
into a fatal bronchitis or pneumonia.

The rash takes about two or three days to get out,
then it begins to fade and the skin to peel off in tiny,

THE HERODS OF OUR DAY 263

branny scales, so small and thin as to be almost invisi-
ble — unlike the huge flakes of scarlet fever. At the
same time all the other symptoms recede.

But, as in scarlet fever, all cases should be treated
alike, by rest, sponging and packing for the fever, light
diet with plenty of milk and fruit, and confinement to
the room for at least ten days after the disappearance
of the fever. The very mildest and most insignificant
of attacks may be followed, through carelessness or
exposure, by a fatal bronchitis. Indeed, in view of the
distressing frequency with which our histories of tuber-
culosis in children contain the words, " Came on after
measles," it is highly' advisable to watch carefully
every child as regards abundant feeding, avoidance
of overwork or overstrain, and of all unnecessary
exposure to infection, wind, or wet, for two months after
an attack of measles instead of the customary two
weeks. As the disease is acutely infectious, the little
victim should be isolated for at least three weeks after
the disappearance of the fever ; but this again, as in the
case of scarlet fever, is emphatically a blessing in dis-
guise from his point of view, as \vell as a protection to
the rest of the community.

Should the" little fever" prove to be whooping-cough,
it will be later still in positively declaring its definite
intentions. The cold or catarrhal stage will be much
milder, the fever lower, the cough a trifle more marked,
but will drag on for from a week to ten days before
anything definite happens. Usually the child is sup-
posed to be suffering with a slight cold, hence the pre-
vailing impression that colds run into whooping-cough,

264 PREVENTABLE DISEASES

if neglected. Then one day the child is suddenly seized
with a coughing fit, consisting of from ten to fifteen
short coughs in rapid succession of increasing intensity,
until all the air seems literally pumped out of the lungs
of the poor little patient; then, with a tremendous
whoop, the youngster gets his breath again and the
diagnosis is made. This distressing performance may
occur only four or five times a day, or it may be re-
peated every half-hour or so. So violent is the paroxysm
that the eyes of the child protrude, it becomes literally
black in the face, and runs to its mother or nurse, or
clutches a chair, to keep from falling.

As the same great nerves which supply the lungs
supply the stomach, the irritation frequently " radiates,"
or spills over, from one division of it to the other, and
the coughing fit is frequently followed by vomiting.
Unexpectedly enough this may often become the most
serious practical symptom of the disease, inasmuch as
the stomach is emptied so frequently that the poor
little victim is unable to retain any nourishment long
enough to absorb it, and may waste away frightfully,
and even literally starve to death, or have its resisting
power so greatly lowered that an attack of bronchial
trouble or bowel disturbance will prove rapidly fatal.

So serious are the disturbances of the circulation all
over the body by these spasmodic suffocation-fits, that
rupture of small blood-vessels may occur in the eyes,
the brain, in the lungs, and on the surface of the skin.
The heart becomes distended, and if originally weak-
ened may be seriously dilated or overstrained ; the
lungs become congested and inflamed, and any of the

THE HERODS OF OUR DAY 265

numerous accidental germs which may be present will
set up a broncho-pneumonia, which is the commonest
cause of death in this disease, as in measles.

Strangely enough, while, as we do not positively know
the germ, and hence cannot state definitely either the
cause or the principal seat of the trouble, it is not gen-
erally believed that the condition of the lungs or the
throat has much to do with the cough.

At all events, it is perfectly idle to treat the disease
with cough mixtures or expectorants. The view toward
which the majority of intelligent observers are inclined
is that whooping-cough is an infection, the germ or
toxin of which attacks the nervous system, and par-
ticularly the great "lung-stomach" (pneumogastric)
nerve. At all events, the only remedies which appear
to have any effect upon the disease are, in the early
stages, mild local antiseptics in the nose and throat,
and later those which diminish the irritability of the
nerves without upsetting the appetite or depressing the
general vigor. The disease is, for all its mildness,
one of the most obstinate known.

A small percentage of cases run a violent course,
in spite of the most intelligent and anxious care, both
medical and household ; but the vast majority of such
complications as occur are either caused by careless-
ness or become serious only if neglected. Treating
all children with whooping-cough as emphatically sick
children, entitled to every care and excuse from exer-
tion, every exemption and privilege that can be given
them until the last whoop has been whooped, would
prevent at least two-thirds of the almost ten thousand

266 PREVENTABLE DISEASES

deaths from whooping-cough that yearly disgrace the
United States.

To sum up in fine: intelligent, effective isolation
of all cases, the mild no less than the severe, would
stamp out these Herods of the twentieth century within
ten years. In the meantime, six weeks' sick-leave, with
all the privileges and care appertaining thereto, will
rob them of two-thirds of their terrors.

CHAPTER XII

APPENDICITIS, OR NATURE'S REMNANT SALE

WE were not made all at once, nor do we go to
pieces all at once, like the "one-boss shay."
This is largely because we are not all of the same age,
clear through. Some parts of us are older than other
parts. We have always felt a difficulty, not to say a deli-
cacy, in determining the age of a given member of the
human species — especially of the gentler sex. Now we
know ihe reason of it. From the biologic point of view,
we are not an individual, but a colony ; not a monarchy,
but a confederacy of organ-states, each with its millions
of cell-citizens. It is not merely editors and crowned
heads who have a biologic right to say "We." There-
fore, obviously, any statement that we make as to our
age can be only in the nature of an average struck be-
tween the ages of our heart, lungs, liver, stomach;
and as these vary in ancientness by thousands of years,
the average must be both vague and misleading. The
only reason why there is a mystery about a woman's
age is that she is so intensely human and natural.
The only statement as to our age that the facts would
strictly justify us in making must partake of the vague-
ness of Mr. A. Ward's famous confession that he was
" between twenty-three summers."

As we individually climb our own family-tree, from
the first, one-celled droplet of animal jelly up, none of

268 PREVENTABLE DISEASES

our organs is older than we are, but a number of them
are younger. The appendix is one of these. Now, by
some curious coincidence, explain it as we may, some
of our oldest organs are youngest, in the sense of most
vigorous, elastic, and resisting, while some of our
youngest are oldest, in the sense of decrepit, feeble,
and unstable. It is perhaps only natural that an organ
like the stomach, for instance, which has a record of
honorable service and active duty millions of years
long, should be better poised, more reliable, and more
resourceful than one which, like the lung or the appen-
dix, has, as it were, a "character" of only about one-
tenth of that length. However this may be, the curious
fact confronts us that scattered about through the
body are structures and fragments, the remains of
organs which at one time in our ancestral career were,
under the then existing circumstances, of utility and
value, but have now become mere survivals, remnants,
— in the language of the day, " back numbers." Some
of these have still a certain degree of utility, though
diminished and still diminishing in size and functional
importance, like our third molars or "wisdom" teeth,
our fifth or "little" toes, our gall-bladder, our coccyx
or tail-bone, the hair-glands scattered all over the now
practically hairless surface of our bodies, and our once
movable ears, which can no longer be "pricked," or
laid back. These, though of far less utility and import-
ance than they obviously were at one time, still earn
their salt, and, though all capable of causing us con-
siderable annoyance on slight provocation, seldom
give rise to serious trouble or inconvenience. There are,

APPENDICITIS 269

however, a few of these " oversights " which are of little
or no known utility, and yet which, either by their
structure or situation, may become the starting-point
of serious trouble.

The best known members of this small group are the
openings through the abdominal wall, which, originally
placed at the strongest and safest position in the quad-
rupedal attitude, are now, in the erect attitude, at the
weakest and most dangerous, and furnish opportunity
for those serious and sometimes fatal escapes of por-
tions of the intestines which we call hernia ; the tonsils ;
and our friend the avpendix vermiformis.

For once its name expresses it exactly. It is an
" appendix," an afterthought ; and it is " vermiformis"
a worm-like creature, — and, like the worm, will some-
times turn when trodden on. Its worm-likeness is sig-
nificant in another sense also, in that it is this very di-
minutiveness in size — the coils into which it is thrown,
the spongy thickness of its walls, and the readiness
with which its calibre or its circulation is blocked —
that is the fundamental cause of its tendency to disease.

The cause of appendicitis is the appendix.

" Despise not the day of small things" is good patho-
logy as well as Scripture. Here we have a little, worm-
shaped tag, or side branch, of the food-tube, barely
three or four inches long, of about the diameter of a
small quill and of a calibre that will barely admit an
ordinary knitting needle. And yet we speak of it with
bated breath. When we remember that this little,
twisted, blind tube opens directly out of one of the
largest pouches of the intestines (the caecum) , and that it

270 PREVENTABLE DISEASES

is easy for anything that may be present in the large
pouch — food, irritating fragments of waste matter,
or bacteria — to find its way into this fatal little trap,
but very difficult to find the way out again, we can form
some idea of what a literal death-trap it may become.

How did such a useless and dangerous structure ever
come to develop in a body in which for the most part
there is mutual helpfulness, utility, and perfect smooth-
ness of working through all the great machine ? To
attempt to answer this would carry us very far back
into ancient history. But to make such backward
search is absolutely the only means of reaching an an-
swer.

"But," some one will object, "how perfectly irra-
tional, not to say absurd, to propose to go back hun-
dreds of thousands of years into ancient history, to
account for a disease which has been discovered —
according to some, invented — within the past twenty-
five years!"

Appendicitis is a mark, not a result, of a high grade of
civilization. To have had an operation for it is one of
the insignia of modern rank and culture. Our new bio-
logic aristocracy, the "Appendix-Free," look down
with gentle disdain upon their appendiciferous fellows
who still bear in their bodies this troublesome mark
of their lowly origin. In short, the general impression
prevails that appendicitis is a new disease, a disease
which has become common, or perhaps occurred at all,
only within the last quarter of a century, and which
therefore — with the usual flying leap of popular logic
— is a serious menace to our future, if it keeps on in-

APPENDICITIS 271

creasing in frequency and ferocity at anything like the
same rate which it has apparently shown for the past
fifteen years.

As this feeling of apprehension is in many minds
quite genuine, it may be well to say briefly, before pro-
ceeding further, first, that, if there be any disease
which absolutely and almost exclusively depends upon
definite peculiarities of structure, it is appendicitis,
and that these structural peculiarities of this tiny,
cramped tag of the food-canal have existed from the
earliest infancy of the race. So it is almost unthinkable
that man should not Jiave been subject to fatal disturb-
ances of this organ from the very earliest times. On
the post-mortem table, the appendix of the lowest sav-
age is the same useless, shriveled, and inflammable
worm as that of the most highly civilized Aryan, though
perhaps an inch or so longer. Secondly, there is abso-
lutely no adequate proof that appendicitis is increasing
in frequency among civilized races It is only about
twenty-five years ago that it was first definitely de-
scribed, and barely fifteen that the profession began at
all generally to recognize it.

But all of us whose memory extends backward a
quarter of a century can clearly recall that, while we did
not see any cases of "appendicitis," we saw dozens
of cases of " acute enteritis," " idiopathic (self-caused)
peritonitis," "acute inflammation of the bowels,"
" acute obstruction of the bowels," of which patients
died both painfully and promptly, and which we now
know were really appendicitis.

In short, from a careful study of all the data, includ-

272 PREVENTABLE DISEASES

ing the claims so frequently made of freedom from ap-
pendicitis on the part of Oriental races, colored races,
less civilized tribes, vegetarians, and others, we are
tending toward the conclusion that the percentage of
appendicitis in a given community is simply the per-
centage of its recognition, — in other words, of the in-
telligence and alertness, first of its physicians, and then
of its laity. As an illustration, my friend Dr. Bloodgood
kindly had the statistics of the surgical patients treated
in the great Johns Hopkins Hospital at Baltimore in-
vestigated for me, and found almost precisely the same
percentage of cases of appendicitis among colored pa-
tients as among white patients.

The earlier impression, first among physicians
and now in the laity, that appendicitis is an almost
invariably fatal disease, is not well founded, and we
now know that a large percentage of cases recover,
at least from the first attack ; so that it is quite possible
for from half to two-thirds of the cases of appendicitis
actually occurring in a given community to escape
recognition, unless promptly reported, carefully ex-
amined, and accurately diagnosed. Thirdly, in spite
of the remarkable notoriety which the disease has at-
tained, the general dread of its occurrence, — which
has been recently well expressed in a statement that
everybody either has had it, or expects to have it, or
knows somebody who has had it, — the actual percent-
age of occurrence of grave appendicitis is small. In
the United States census of 1900, which was the first
census in which it was recognized as a separate cause
of death, it was responsible for only 5000 deaths in the

APPENDICITIS 273

entire United States for the ten years preceding, or
about one death in two hundred. This rate is corrobo-
rated by the data, now reaching into thousands, from
the post-mortem rooms of our great hospitals, which
report an average of between a half and one per cent.
A disease which, in spite of the widespread terror of it,
kills only one in two hundred of those who actually
die — or about one in every ten thousand of our popu-
lation — is certainly nothing to become seriously excited
over from a racial point of view.

While appendicitis is one of the "realest" and most
substantial of diseases^ and, in its serious form, highly
dangerous to life, there can be little doubt that there
has come, first of all, a state of mind almost approach-
ing panic in regard to it; and, second, a preference for
it as a diagnosis, as so much more distingue than such
plebeian names as " colic," " indigestion," " enteritis,"
or the plain old Saxon " belly-ache," which has reached
almost the proportions of a fad. It is certain that
nowadays physicians have almost as frequently to re-
fuse to operate on those who are clamoring for the
distinction, as to urge a needed operation upon those
unwilling to submit to it.

The satirical proposal that a "closed season" should
be established by law for appendicitis as for game birds,
during which none might be taken, would apply almost
as often to the laity as to the profession, even the sur-
gical half.

Since the chief cause of appendicitis is the appendix,
the first question for disposal is, How did the appendix
become an appendix? To this biology can render a

274 PREVENTABLE DISEASES

fairly satisfactory answer. It is the remains of one of
Mother Nature's experiments with her 'prentice hand
upon the mammalian food-tube. As is now generally
known, the food-canal in animals was originally a
comparatively straight tube, running the length of the
body from mouth to anus. It early distends into a
moderate pouch, about a third of the way down from
the mouth, forming a stomach, or storage and churning-
place for the food. Below this, it lengthens into coils
(the so-called small intestine), which, as the body be-
comes more complex, increase in number and length
until they reach four to ten times the length of the body.
Later, the lower third of the tube distends and saccu-
lates out into a so-called large intestine, in which the
last remnants of nutritive material and of moisture are
extracted from the food-residues before they are dis-
charged from the body. Just at the junction of this
large intestine with the small intestine, nature took
it into her head to develop a second pouch, a sort of
copy of the stomach. This pouch, from the fact that it
ends in a blind sac, is known as the ccecum (or " blind "
pouch), and is apparently simply a means of delaying
the passage of the foodstuffs until all the nutriment and
moisture have been absorbed out of them for the ser-
vice of the body. Naturally, it has developed to the
largest degree and size in those animals which have
lived upon the bulkiest and grassiest of foods, the so-
called Herbivora, or grass-eaters. In the Carnivora,
or flesh-eaters, it is usually small, and in one family,
the bears, entirely absent. This pouch is no mere figure
of speech, as may be gathered from the fact that in

APPENDICITIS 275

certain of the rodent Herbivora, like the common
guinea-pig, it may have a capacity equal to all of the
rest of the alimentary canal, and in the horse it will
hold something like four times as much as the stomach.
Oddly enough, among the grass-eaters, for some reason
which we do not understand, it appears to occur in a
sort of inverse proportion to the stomach ; those which
have large, sacculate, pouched stomachs, like the cow,
sheep, and the ruminants generally, having smaller
cceca. In other Herbivora with small stomachs, like
the rabbit and the horse, it develops greater size.

Our primitive ancestors were mixed feeders, and,
though probably more largely herbivorous than we are
to-day, had a medium-sized caecum, and maintained
it up to the point at which the anthropoid apes began
to branch off from our family-tree. But at about this
point, for some reason, possibly connected with the
increasing variety and improved quality and concen-
tration of the food, due to greater intelligence and
ability to obtain it, this large ccecum became unneces-
sary, and began to shrivel.

Here, however, is where nature makes her first after-
thought mistake. Instead of allowing this pouch to con-
tract and shrivel uniformly throughout its entire length,
she allowed the farther (or distal) two-thirds of it
to shrivel down at a much faster rate than the central
(or proximal) third ; so that the once evenly distended
sausage-shaped pouch, about six to eight inches long
and two inches in diameter, has become distorted down
into a narrow, contracted end portion, about a quarter
of an inch in diameter, and a distended first portion,

276 PREVENTABLE DISEASES

for all the world like a corncob pipe with a crooked
stem and an unusually large bowl. And behold — the
modern appendix vermiformis, with all its fatal possi-
bilities !

If we want something distinctly human to be proud
of, we may take the appendix, for man is the only
animal that has this in its perfection. A somewhat
similarly shriveled last four inches of the caecum is found
in the anthropoid apes and in the wombat, a burrowing
marsupial of Australia. In some of the monkeys, and
in certain rodents like the guinea-pig, a curious imi-
tation appendix is found, which consists simply of
a contracted last four or five inches of the caecum,
which, however, on distention with air, is found to
relax and expand until of the same size as the rest of
the gut.

The most strikingly and distinctly human thing about
us is not our brain, but our appendix. And, while
recognizing its power for mischief, it is only fair to
remember that it is an incident and a mark of progress,
of difficulties overcome, of dangers survived. In all
probability, it was our change to a more carnivorous
diet, and consequently predatory habits, which ena-
bled our ancestors to step out from the ruck of the
"Bandar-Log," the Monkey Peoples. An increase in
carnivorousness must have been a powerful help to our
survival, both by widening our range of diet, so that
we could live and thrive on anything and everything
we could get our hands on, and by inspiring greater re-
spect in the bosoms of our enemies. Let us therefore
respect the appendix as a mark and sign of historic

APPENDICITIS 277

progress and triumph, even while recognizing to the
full its unfortunate capabilities for mischief.

But what has this ancient history to do with us in
the twentieth century? Much in every way. First,
because it furnishes the physical basis of our troubles ;
and second, and most important, because, like other
history, it is not merely repeating itself, but continuing.
This process of shriveling on the part of the appendix
is not ancient history at all, but exceedingly modern ;
indeed, it is still going on in our bodies, unless we are
over sixty-five years of age.

In the first place, we have actually passed through
two-thirds of this process in our own individual experi-
ence.

At the first appearance of the ccecum, or blind pouch,
in our prenatal life, it is of the same calibre as the rest
of the intestine, and of uniform size from base to tip.
About three weeks later the tip begins to shrivel, and
from this on the process steadily continues, until at
birth it has contracted to about one-fifteenth of the bulk
of the ccecum. But the process does n't stop here,
though its progress is slower. By about the fifth year
of life the stem of the cseco-appendix pipe has dimin-
ished to about one- thirtieth of the size of the bowl,
which is the proportion that it maintains practically
throughout the rest of adult life. For a long time we
concluded that the process was here finished, and
that the appendix underwent no further spontaneous
changes during life; but, after appendicitis became
clearly recognized, a more careful study was made of
the condition of the appendix in bodies coming to the

278 PREVENTABLE DISEASES

post-mortem table, dead of other diseases, at all ages
of life. This quickly revealed an extraordinary and
most significant fact, that, while the appendix was
no longer decreasing in apparent size, its internal capa-
city or calibre was still diminishing, and at such a rate
that by the thirty-fifth year it had contracted down
so as to become cut off from the cavity of the caecum
in about twenty-five to thirty per cent of all individuals.
By the forty-fifth year, according to the anatomist
Ribbert (who has made the most extensive study of the
subject), nearly fifty per cent of all appendices are
found to be cut off, and by the sixty-fifth year nearly
seventy per cent.

This explains at once why appendicitis is so emphati-
cally a disease of young life, the largest number of cases
occurring before the twenty-fifth year (fifty per cent
of all cases occur between ten and thirty years of age) ,
and becoming distinctly rarer after the thirty-fifth,
only about twenty per cent occurring after this age.
As soon as the cavity of the appendix is cut off from
that of the intestine, it is of course obvious that infec-
tious or other irritating materials can no longer enter
its cavity to cause trouble, although, of course, it is
still subject to accidents due to kinks, or twists, or
interference with its blood-supply ; but these are not so
dangerous, providing there be no infectious germs
present.

Here, then, we have a clear and adequate physical
basis for appendicitis. A small, twisted, shriveling spur
or side twig of the intestine, opening from a point which
has become a kind of settling basin in the food-tube,

APPENDICITIS 279

its mouth gaping, as it were, to admit any poisonous
or irritating food, infectious materials, disease-germs,
the ordinary bacteria which swarm in the alimentary
canal, or irritating foreign bodies, like particles of dirt,
sand, hairs, fragments of bone, pins, etc., which may
have been accidentally swallowed. Once these irritat-
ing and infectious materials have entered it, spasm of
its muscular coat is promptly set up, their escape is
blocked, and a violent inflammation easily follows,
which may end in rupture, perforation, or gangrene.

Not only may any infection which is sweeping along
the alimentary canal, thrown off and resisted by the
vigorous, full-sized, well-fed intestine, find a point
of lowered resistance and an easy victim for its attack
in the appendix, but there is now much evidence to
indicate that the ordinary bacteria which inhabit the
alimentary canal, particularly that first cousin of the
typhoid bacillus, the colon bacillus, when once trapped
in this cul-de-sac, may quickly acquire dangerous
powers and set up an acute inflammation. It is not
necessary to suppose that any particular germ or infec-
tion causes appendicitis. Any one which passes through,
or attacks, the alimentary canal is quite capable of it,
and probably does cause its share of the attacks.

Numerous attempts have been made to show that
appendicitis is particularly likely to follow typhoid
fever, rheumatism, influenza, tonsilitis, and half a
dozen other infectious or inflammatory processes.
But about all that has been demonstrated is that it may
follow any of them, though in none with sufficient fre-
quency or constancy to enable it to be regarded as

280 PREVENTABLE DISEASES

one of the chief or even one of the important causes
of the disease.

One dread, however, we may relieve our anxious
souls of, and that is the famous grape-seed or cherry-
stone terror. To use a Hibernianism, one of our most
positive conclusions in regard to the cause of appendi-
citis is a negative one : that it is not chiefly, or indeed
frequently, due to the presence of foreign bodies. This
was a most natural conclusion in the early days of the
disease, since, given a tiny blind pouch with a con-
stricted opening gaping upon the cavity of the food-
canal, nothing could be more natural than to suppose
that small irritating food remnants or foreign bodies,
slipping into it and becoming lodged, would block
it and give rise to serious inflammation. And, more-
over, this a priori expectation was apparently con-
firmed by the discovery, in many appendices removed
by operation, of small oval or rounded masses, closely
resembling the seed of some vegetable or fruit. • Where-
upon anxious mothers promptly proceeded to order
their children to "spit out," with even more religious
care than formerly, every grape-seed and cherry-stone.
The increased use of fresh and preserved fruits was
actually gravely cited, particularly by our Continental
brethren, as one of the causes of this new American
disease. Barely ten years ago I was spending the sum-
mer in the Adirondacks, and was bitterly reproached
by the host of one of the Lake hotels, because the pro-
fession had so terrified the public about the dangers of
appendicitis from fruit-seeds that he was utterly unable
to serve upon his tables a large stock of delicious pre-

APPENDICITIS 281

served and canned raspberries, blackberries, and grapes
which he had put up the previous years. "Why,"
he said, " more than half the people that come up here
will no more eat them than they would poison, for fear
that some of the seeds will give 'em appendicitis."
This dread, however, has been deprived of all rational
basis, first, by finding that many inflamed appendices
removed, after the operation became more common,
contained no foreign body whatever; secondly, that
many perfectly healthy appendices examined on the
post-mortem table, death being due to other diseases,
contain these apparently foreign bodies; and thirdly,
that when these "foreign bodies" were cut into, they
were found to be not seeds or pits of any description,
but hardened and, in some cases, partially calcareous
masses of the faeces.

We are in a nearly similar position in regard to the
third alleged cause of appendicitis, and that is food.
Many are the accusations which have been made in this
field. On the one hand, meat and animal foods gen-
erally have been denounced, on account of their sup-
posed "heating" or "uric-acid-forming" properties;
while on the other, vegetables and fruits have been
equally hotly incriminated, on account of their seeds,
fibres, husks, and irritating substances, and the danger
of their being contaminated by bacteria and other par-
asites freifl the soil. These charges appear to have little
adequate foundation, and, so far as we are in a posi-
tion now to judge, the only way a food can give, or be
accessory to, appendicitis is by its being taken in such
excessive amounts as to set up fermentive or putrefac-

282 PREVENTABLE DISEASES

tive changes in the alimentary canal, or by its being
in an unsound, decaying, or actually diseased condition.
Any amounts or quality of food which are capable
of giving rise to an attack of acute indigestion may
secondarily lead to an attack of appendicitis. The only
single article of diet whose ingestion is declared by
Osier to be rather frequently followed by an attack
of appendicitis is the peanut.

Therefore, the best thing to do in the way of taking
precautions against the occurrence of appendicitis is,
in the language of the day, to " forget it" as completely
as possible, reassuring ourselves that, in spite of its
extraordinary notoriety and popularity, it is a com-
paratively rare disease in its fatal form, responsible
for not more than one-half of one per cent of the
deaths, and that the older we grow, the better become
our chances of escaping it.

Whatever we may have decided in regard to our
brains, by the time we reach fifty, we may feel reason-
ably sure we've no appendix.

But the question will at once arise, if the appendix
be so tiny in size, so insignificant in capacity, and so
devoid of useful function, what is the use of disturbing
ourselves over the question of what may become of it ?
If it is going to decay and drop off, why not permit it to
do so, with the philosophic indifference with which
we would sacrifice the tip of our little fingers in a plan-
ing-mill ? Here, however, is just the rub, and the fact
that gives to appendicitis all its terrors, and to the
question of what to do in each particular case its
difficulties and perplexities.

APPENDICITIS 283

The appendix does not, unfortunately, hang out
from the surface of the body, where it could peacefully
decay and drop off without prejudice to the rest of the
body, or be quickly lopped off in the event of its giving
trouble. On the contrary, it projects its stubby and
insignificant length right into the midst of the most
delicate and susceptible cavity of the body, the general
cavity of the abdomen, or peritoneum. The thin, sensi-
tive sheet of peritoneum which lines this cavity covers
every fold and part of the food-tube, from the stomach
down to the rectum. And when once infection or inflam-
mation has occurred at any point in it, there is nothing to
prevent its spreading like a prairie fire, all over the en-
tire abdominal cavity from diaphragm to pelvis. If this
wretched little remnant were a coil of explosive fuse
within the brain-cavity itself, which any jar might set
off, it could hardly be richer in possibilities of danger.

A redeeming feature of appendicitis is that the ap-
pendix lies — so to speak — in a corner, or wide-
mouthed pouch, of the great peritoneal cavity; and if
the inflammation set up in it can be "walled off" from
the rest of the peritoneal cavity, and limited strictly
to this little corner or pouch, all will be well. This is
what occurs in those cases of severe appendicitis which
spontaneously recover. If, however, this disturbance
bursts its barriers, and lights up an inflammation of the
entire peritoneal cavity, then the result is likely to be
a fatal one. Just how far nature can be trusted in each
particular case to limit and stamp out the process in this
manner is the core of the problem that confronts us,
as attending physicians.

284 PREVENTABLE DISEASES

In the majority of cases, fortunately, the peritoneal
fire brigade acts promptly, pours out a wall of exudate,
and locks up the appendix in a living prison, to fight
out its own battles and sink or swim by itself. But un-
fortunately, in a minority of cases, by a wretched sort
of "senatorial courtesy" which exists in the body, the
appendix is given its ancestral or traditional rights and
allowed to inflict its petty troubles upon the entire ab-
dominal cavity, and include the body in its downfall.

Lastly come the two most pertinent and appealing
questions : —

What is the outlook for me if I should develop
appendicitis ? And what is to be done ?

In regard to the first of these, it is safe to say that
our answer is much less alarming than it was in the
earlier stage of our knowledge. Naturally enough, in
the beginning, only the severest and most unmistak-
able forms of the disease and those which showed no
tendency to localization, were recognized, or at least
came under the eye of the surgeon ; and as a large per-
centage of these resulted fatally, the conclusion was
reached, both in the medical profession and by the
laity, that appendicitis was an exceedingly dangerous
'disease, with a high fatality in all cases. As, however,
physicians became more expert in the recognition of
the disease, it was discovered to be vastly more com-
mon, while side by side came the consoling knowledge
that a considerable percentage of cases got well of
themselves, in the sense of the inflammation being
limited to the lower right-hand corner of the abdom-
inal cavity, though, of course, with the possibility of

APPENDICITIS 285

leaving a smouldering fuse which might light up an-
other explosion under any stress in future.

Further, as the attention of the post-mortem inves-
tigators at our large hospitals was directed to the sub-
ject, it was found that a very considerable percentage
of all bodies, ranging from twenty to — according
to some estimates — as high as sixty per cent, showed
changes in the appendix and its neighborhood which
were believed to be due to old inflammations ; so that,
while it is possible to speak only with great caution
and reserve, the balance of opinion among clinicians
and pathologists of wi^e experience and the more con-
servative surgeons appears to be that from one-half to
two-thirds of all cases of appendicitis will recover of
themselves, in the sense of subsiding more or less
permanently, without causing death.

On the other hand, it must be remembered that the
appendix is an organ which, so far as any evidence has
been adduced, is entirely without useful function;
that it is in process of shriveling and disappearance,
if left entirely alone, and that the best result which can
be expected from a self-cured attack of appendicitis
is the destruction of the appendix and its elimination
as a further possible cause of mischief. By avoiding
an operation in appendicitis, we may be practically
certain that we save nothing that is worth saving —
except the fee. Moreover, even though only from
one-fourth to one-third of all cases develop serious
complications, you never can be quite sure in which
division your particular case will fall.

The situation is in fact a little bit like one related

286 PREVENTABLE DISEASES

in the experience of Edison, the inventor. The trustees
of a church in a neighboring town had just completed
a beautiful new church building with a high spire, pro-
jecting far above any other building in the town. When
it was nearing completion, the question arose, should
they put on a lightning-rod. The great church itself
had strained their financial resources, and one party
in the board were of the opinion that they should avoid
this unnecessary expense, supporting their economic
attitude by the argument that, to put on a lightning-
rod, would argue a lack of trust in Providence. Finally,
after much debate, it was decided, as the great elec-
trician was readily accessible, to submit the question
to him. Mr. Edison listened gravely to the arguments
presented, pro and con.

" What is the height of the building, gentlemen ? "

The number of feet was given.

"How much is that above that of any surrounding
structures?'*

The data were supplied.

"It is a church, you say?"

" Yes."

" Well," said the great man, " on the whole, I should
advise you to put on a lightning-rod. Providence is apt
to be, at times, a trifle absent-minded."

The chances are in favor of your recovery, but —
put on a lightning-rod, in the shape of the best and
most competent doctor you know, and be guided en-
tirely by his opinion. An attack of appendicitis is like
shooting the Grand Lachine Rapids. Probably you
will come through all right; but there is always the

APPENDICITIS 287

possibility of landing at a moment's notice on the rocks
or in the whirlpools. With a good pilot your risk
does n't exceed a fraction of one per cent. And fortu-
nately this condition has been not merety theoretically
but practically reached already; for the later series
of case-groups of appendicitis treated in this intelligent
way by cooperation between the physician and surgeon
from the start, with prompt interference in those cases
which to the practiced eye show signs of making
trouble, has reduced the actual recorded mortality of
the disease to between two and five per cent. Even
of those cases which come to operation now, the death-
rate has been reduced as low as five per cent, in series
of from 400 to 600 successive operations. When we
contrast this with the first results of operation, when
the cases as a rule were seen too late for the best time
of interference, and from twenty per cent to thirty per
cent died ; and with the intermediate stage, when sur-
geons as a rule were inclined to advise operation at the
earliest possible moment that the disease could be
recognized, and from ten per cent to fifteen per cent
died, we can see how steady the improvement has been,
and how encouraging the outlook is for the future.

Cases which have weathered one attack of appendi-
citis are of course by no means free from the risk of
another. Indeed, at one time it was believed that a
recurrence was almost certain to occur. Later investi-
gations, based upon larger numbers of cases, now
running up into the thousands, give the reassuring
result that though this danger is a real one, it is not so
great as it was at one time supposed, as the average

288 PREVENTABLE DISEASES

number in whom a second attack occurs appears to be
about twenty per cent. This, however, is a large enough
risk to be worthy of serious consideration ; and in view
of the fact that the mortality of operations done be-
tween attacks is less than one per cent, it is generally
the feeling of the profession that, where there is any
appreciable soreness, or tenderness, or liability to
attacks of pain in the right iliac region, in an individual
who has had one attack of appendicitis, the really con-
servative and prudent procedure is to have the source
of the trouble removed once and for all.

The four principal symptoms of appendicitis are:
pain, which is usually felt most keenly somewhere be-
tween the umbilicus and the right groin, though this
is by no means invariable; tenderness in that same
region upon pressure; rigidity of the muscles of the
abdominal wall on the right side; and temperature,
or fever.

No matter how much and how variegated pain you
may have in the abdomen, or how high your tempera-
ture may run, if you are not distinctly sore on firm
pressure down in this right lower or southwest quad-
rant of the abdomen, — but be careful not to press too
hard, it is n't safe, — you may feel fairly sure that you
have n't got appendicitis. If you are, you may still not
have it, but you 'd better send for the doctor, to be sure.

CHAPTER XIII

MALARIA: THE PESTILENCE THAT WALKETH IN DARK-
NESS; THE GREATEST FOE OF THE PIONEER

MALARIA has probably killed more human be-
ings than all the wars that have ever devastated
the globe. Some day the epic of medicine will be writ-
ten, and will show what a large and unexpected part it
has played in the progress of civilization. Valuable and
essential to that progress as were the classic great dis-
coveries of fire, ships, wheeled carriages, steam,
gunpowder, and electricity, they are almost paralleled
by the victories of sanitary science and medicine in
the cure and prevention of that greatest disrupter of
the social organism — disease. No sooner does the
primitive human hive reach that degree of density
which is the one indispensable condition of civiliza-
tion, than it is apt to breed a pestilence which will
decimate and even scatter it. Smallpox, cholera, and
bubonic plague have bkzed up at intervals in the
centres of greatest congestion, to scourge and shatter
the civilization that has bred them. No civilization
could long make headway while it incurred the dangers
from its own dirtiness; and to-day the most massive
and imposing remains of past and gone empires are
their aqueducts, their sewers, and their public baths.
What chance has a community of building up a steady
and efficient working force, or even an army, large

290 PREVENTABLE DISEASES

enough for adequate defense, when it has a constant
death-rate of ten per cent per annum, and an ever re-
current one of twenty to thirty per cent, by the sweep
of some pestilence ? The bubonic plague alone is esti-
mated to have slain thirty millions of people within two
centuries in Mediaeval Europe, and to have turned
whole provinces into little better than deserts.

In malaria, however, we have a disease enemy of
somewhat different class and habits. While other great
infections attack man usually where he is strongest and
most numerous, malaria, on the contrary, lies in wait
for him where he is weakest and most scattered, upon
the frontiers of civilization and the borders of the wil-
derness. It is only of late years that we have begun to
realize what a deadly and persistent enemy of the
frontiersman and pioneer it is. We used to hear much
of climate as an obstacle to civilization and barrier to
settlement. Now, for climate we read "malaria."
Whether on the prairies or even the tundras of the
North, or by the jungles and swamps of the Equator,
the thing that killed was eight times out of ten the
winged messenger of death with his burden of malaria-
infection. The "chills and fever," " fevernager,"
"mylary," that chattered the teeth and racked the
joints of the pioneer, from Michigan to Mississippi,
was one and the same plague with the deadly " jungle
fever," "African fever," "black fever" of the tropics,
from Panama to Singapore. Hardly a generation ago,
along the advancing front of civilization in the Middle
West, the whole life of the community was colored
with a malarial tinge and the taste of quinine was

MALARIA 291

as familiar as that of sugar. To this day, over some-
thing like three-quarters of the area of these United
States, the South, Middle West, and Far West, if you
feel headachy and bilious and "run down," you sum
it all up by saying that you are feeling "malarious."
Dwellers upon the rich bottom-lands expected to shake
every spring and fall with almost the same regularity
as they put on and shed their winter clothing. Readers
of Frank Stockton will remember the gales of merri-
ment excited by his quaint touch of the incongruous
in making the prospective bridegroom of the immortal
Pomona change the,* date of their wedding day from
Tuesday to Monday, because, on figuring the matter
out, he had discovered that Tuesday was his "chill-
day."

Though the sufferer from ague seldom received very
much sympathy at the time, but was considered a
fair butt for genial ridicule and chaff, yet even there
the trouble had its serious side. Through all those
communities there stalked a well-known and dreaded
spectre, the so-called "congestive chill," what is now
known in technical language as the pernicious malarial
paroxysm. These were like the three warnings of
death in the old parable. You would probably survive
the first and might never have another ; but if you had
your second, it was considered equivalent to a notice
to quit the country promptly and without counting the
cost. In my boyhood days in the Middle West, I can
recall hearing old pioneers tell of little groups of one
or more families moving out on to some particularly
rich and virgin bottom-land and losing two or three

292 PREVENTABLE DISEASES

or more members out of each family by congestive
chills within the first year, and in some cases being
driven in from the outpost and back to civilization by
the fearful death-loss.

A pall of dread hangs over the whole west coast of
Africa. The factories and trading-posts are haunted
by the ghosts of former agents and explorers who have
died there. Some years ago one German company
had the sinister record that of its hundreds of agents
sent out to the Gold Coast under a three years' con-
tract, not one had fulfilled the term! All had either
died, or been invalided and returned home. It was
malaria more than any other five influences combined
that thwarted the French in their attempt to dig the
Panama Canal and that made the Panama Railroad
bear the ghastly stigma of having built its forty miles
of track with a human body for every tie.

Malaria ever has been, and is yet, the great barrier
against the invasion of the tropics by the white races ;
nor has its injurious influence been confined to the
deaths that it causes, for these gaps in the fighting
line might be filled by fresh levies drawn from the
wholesome North. Its fearfully depressing and degen-
erating effects upon even those who recover from its
attacks have been still more injurious. It has been
held by careful students of tropical disease and con-
ditions that no small part of that singular apathy and
indifference which steal over the mind and body of
the white colonist in the tropics, numbing even his
moral sense, and alternating with furious outbursts
of what the French have termed "tropical wrath,"

MALARIA 293

characterized by unnatural cruelty and abnormal dis-
regard for the rights of others, is the deadly work of
malaria. It is the most powerful cause, not merely of
the extinction of the white colonist in the tropics, but
of the peculiar degeneracy — physical, mental, and
moral — which is apt to steal over even the survivors
who succeed in retaining a foothold. Two particu-
larly ingenious investigators have even advanced the
theory that the importation of malaria into the islands
of Greece and the Italian peninsula by soldiers return-
ing from African and Southern Asiatic conquests
had much to do with accelerating, if not actually pro-
moting, the classic decay of both of these superb civili-
zations.

To come nearer home, there can be little question
that the baneful, persistent influence of malaria,
together with the hookworm disease, has had much to
do both with the degeneracy of the Southern " cracker,"
or "mean white," and with those wild oubursts of
primitive ferocity in all classes which take the form
of White Cap raids and lynching mobs.

However this may be, the disease and the coloniza-
tion habit brought in a crude way their own remedy.
The Spanish conquerors of Peru were told by the na-
tives that a certain bark which grew upon the slopes
of the Andes was a sovereign remedy for those terrible
ague seizures. Indian remedies did not stand as high
in popular esteem as they do now; but they were in
desperate straits and jumped at the chance. To their
delight, it proved a positive specific, and a Spanish
lady of rank, the Countess Chincona, was so delighted

294 PREVENTABLE DISEASES

with her own recovery that she carried back a package
of the precious Peruvian bark on her return to Europe,
and endeavored to introduce it. So furious was the
opposition of the Church, however, to this "pagan"
remedy that she was completely defeated in her praise-
worthy attempt and was obliged to confine her minis-
trations to those who belonged to her, the peasantry
on her own estate. About half a century later, the new
remedy excited so much discussion by the numerous
cures that it effected, that it was considered worthy
of a special council of the Jesuits, who formally pro-
nounced it suitable for the use of the faithful, thereby
attaching to it for many years the name of " Jesuit's
bark." Virtue, however, is sometimes rewarded in this
world, and the devoted and enlightened countess has,
all unknown to herself, attained immortality by attach-
ing her name, Chincona, softened into cinchona,,
and hardened into quinine, to the greatest therapeutic
gift of the gods to mankind. It is not too much to say
that the modern colonization of the tropics and sub-
tropics by Northern races, which is one of the greatest
and most significant triumphs of our civilization,
would have been almost impossible without it. Its
advance depended upon two powders, one white and
the other black, — quinine and gunpowder.

For nearly three centuries we rested content with the
knowledge that in quinine we had a remedy for malaria,
which, if administered at the proper time and in ade-
quate doses, would break up and cure ninety per cent
of all cases. Just how it did it we were utterly in the
dark, and many were the speculations that were in-

MALARIA 295

dulged in. It was not until 1880, that Laveran, a French
army surgeon stationed in Algeria, announced the
discovery in the blood of malarial patients of an organ-
ism which at first bore his name, the Hematozoon-
Laveran, now known as the Plasmodium malaria.
This organism, of all curious places, burrowed into
and found a home in the little red corpuscles of the
blood. At periods of forty-eight hours it ripened a
crop of spores, and would burst out of the corpuscles,
scattering throughout the blood and the tissues of the
body, and producing the famous paroxysm. This

accounted for the most curious and well-marked fea-
/

ture of the disease, namely, its intermittent character,
chill and fever one day, and then a day of comparative
health, followed by another chill day and so on, as
long as the infection continued. One problem, how-
ever, was left open, and that was why certain forms
of the disease had their chills every fourth day and so
were called quartan ague. This was quickly solved
by the discovery of another form of the organism,
which ripened its spores in three days instead of two.
So the whole curious rhythm of the disease was estab-
lished by the rate of breeding or ripening of the spores
of the organism. Later still another form was discov-
ered, which had no such regular period of incubation
and gave rise to the so-called irregular, or autumnal,
malarial fevers. That form of the fever which had a
paroxysm every day, the classic quotidian ague, re-
mained a puzzle for a little longer, but was finally
discovered to be due chiefly to the presence of two
broods, or infections, of the organism, which ripened on

296 PREVENTABLE DISEASES

alternate days and hence kept the entire time of the
unfortunate patient occupied.

The mystery of the remedial effect of quinine was
also solved, as it was found that, if administered at
the time which centuries of experience has shown us
to be the most effective, between or shortly before the
paroxysms, it either prevented sporulation or killed
the spores. So that at one triumphant stroke the mys-
tery of centuries was cleared up.

But here will challenge some twentieth-century
Gradgrind: "This is all very pretty from the point of
view of abstract science, but what is the practical
value of it ? The discovery of the plasmodium and its
peculiarities has merely shown us the how and the why
of a fact that we had known well and utilized for cen-
turies, namely, that quinine will cure malaria." Just
listen to what follows. The story of the plasmodium
is one of the most beautiful illustrations of the fact that
there is no such thing as useless or unpractical know-
ledge. The only thing that makes any knowledge un-
practical is our more or less temporary ignorance
of how to apply it. The first question which instantly
raised itself was, "How did the plasmodium get into
human blood?" The very sickle-shape of the plas-
modium turned itself into an interrogation mark.
The first clew that was given was the new and interest-
ing one that this organism was a new departure in
the germ line in that it was an animal, instead of a
plant, like all the other hitherto known bacilli, bac-
teria, and other disease-germs.

It may be remarked in passing that its discovery

MALARIA 297

had another incidental practical lesson of enormous
value, and that was that it paved the way for the iden-
tification of a whole class of animal parasites causing
infectious diseases, which already includes the organ-
isms of Texas fever in cattle, dourine in horses, the
tsetse fly disease, the dreaded sleeping sickness, and
finally such world-renowned plagues as syphilis and
perhaps smallpox.

Being an animal, the plasmodium naturally would
not grow upon culture-media like the vegetable bacilli
and bacteria, and this very fact had delayed its recog-
nition, but raised at once the probability that it must
be conveyed into tKe human body by some other
animal. Obviously, the only animals that bite our
human species with sufficient frequency and regularity
to act as transmitters of such a common disease are
those Ishmaelites of the animal world, the insects.
As all the evidence pointed toward malaria being
contracted in the open air, attested by its popular
though unscientific name mal-aria, " bad air," and as
of all forms of "bad air" the night air was incom-
parably the worst, it must be some insect which flew
and bit by night; which by Sherlock Holmes's pro-
cess promptly led the mosquito into the dock as the
suspected criminal. It was n't long before he was,
in the immortal language of Mr. Devery, "caught
with the goods on"; and in 1895 Dr. Ronald Ross,
of the Indian Medical Service, discovered and posi-
tively identified the plasmodium undergoing a cycle
of its development in the body of the mosquito. He
attempted to communicate the disease to birds and

298 PREVENTABLE DISEASES

animals by allowing infected mosquitoes to bite them,
but was unsuccessful. Two Italian investigators,
Bignami and Grassi, saw that the problem was one
for human experiment and that nothing less would
solve it. Volunteers were called for and promptly
offered themselves. Their blood was carefully exam-
ined to make sure that they were not suffering from
any latent form of malaria. They then allowed them-
selves to be bitten by infected mosquitoes, and within
periods varying from six to ten days, eight-tenths
of them developed the disease. It may be some con-
solation to our national pride to know that although
the organism was first identified in the mosquito by an
Englishman and its transmission to human beings in
its bite by Italians, the first definite and carefully
worked-out statement of the relation of the mosquito
to malaria was made by an American, King of Wash-
ington, in 1882 ; though it is only fair to say that sug-
gestions of the possible connection between mosquitoes
and malaria had, so to speak, been in the air and been
made from scores of different sources, from the age
of Augustus onward.

Another mystery was solved — and what a flood
of light it did pour upon our speculations as to the how
and wherefore of the catching of malaria! In some
respects it curiously corroborated and increased our
respect for popular beliefs and impressions. While
"bad air" had nothing to do with causing the disease,
except in so far as it was inhabited by songsters of the
Anopheles genus, yet it was precisely the air of marshy
places which was most likely to be " bad " in this sense.

MALARIA 299

So that, while in one sense those local wiseacres, who
would point out to you the pearly mists of evening
as they rose over low-lying meadows and bottom-lands,
and inform you that there before your very eyes was
the "mylary just a-risin' out of the ground," were
ludicrously mistaken, in another their practical con-
clusion was absolutely sound ; for it is in just such air,
at such levels above the surface of the water, that the
Anopheles most delights to disport himself. Further-
more, while all raw or misty air is " bad," the night air
is infinitely more so than that of the day, because this
is the time at which mosquitoes are chiefly abroad. In
fact, there can be little doubt that this is part of the
foundation for that rabid and unreasonable dread of the
night air which we fresh-air crusaders find the bitterest
and most tenacious foe we have to fight. We have liter-
ally discovered the Powers of Darkness in both visible
and audible form, and they have wings and bite, just
like the vampire.

It was also a widespread belief in malarial regions
that the hours when you are most likely to " git mylary
inter yer system" were those just before and just after
sundown ; and now entomologists inform us that these
are precisely the hours at which the Anopheles mos-
quito, the only genus that carries malaria, flies abroad.

Of course, a number of popular causes, such as bad
drainage, the drinking of water from shallow surface
wells, damp subsoils under the houses, and especially
that peculiarly widespread and firmly held article
of belief that new settlements, where large areas of
prairie sod were being freshly upturned by the plough,

300 PREVENTABLE DISEASES

were peculiarly liable to the attack and spread of ma-
laria, had to go by the board, — with this important
reservation, however, that almost every one of these
alleged causes either implied or was pretty safe to be
associated with pools or swamps of stagnant water
in the neighborhood, which would furnish breeding-
spots for the mosquitoes.

The discovery explains at once a score of hitherto
puzzling facts as to the distribution of malaria. Why,
for instance, in all tropical or other malarious countries,
those who slept in second and third story bedrooms
were less likely to contract the disease, supposedly
because " bad air did n't rise to that height," is
clearly seen to be due to the fact that the mosquito
seldom flies more than ten or twelve feet above the
level of the ground or marsh in which he breeds, ex-
cept when swept by prevailing winds. It also explained
why in our Western and Southwestern states the in-
habitants of the houses situated on the south bank
of a river, though but a short distance back from the
stream, would suffer very slightly from malaria, while
those living upon the north bank, half a mile back, or
even upon bluffs fifteen or twenty feet above the water
level, were simply plagued with it. The prevailing
winds during the summer are from the south and mos-
quitoes cannot fly a foot against the wind, but will fly
hundreds of yards, and even the best part of a mile,
with it. The well-known seasonal preference of the
disease for warm spring and summer months, and its
prompt subsidence after a killing frost, were seen
simply to be due to the influence of the weather upon

MALARIA 301

the flight of mosquitoes. Shakespeare's favorite refer-
ence to "the sun of March that breedeth agues" has
been placed upon a solid entomological basis by the
discovery that, like his pious little brother insect, the
bee, the one converted and church-going member of
a large criminal family, the mosquito hies himself
abroad on his affairs at the very first gleam of spring
sunshine, and will even reappear upon a warm,
sunny day in November or December. Perhaps
even some of the popular prejudice against "un-
seasonable weather" in winter may be traceable to
this fact. ^

Granted that mosquitoes do cause and are the only
cause of malaria, what are you going to do about it ?
At first sight any campaign against malaria which in-
volves the extermination of the mosquito would appear
about as hopeless as Mrs. Partington's attempt to sweep
back the rising Atlantic tide with her broom. But a
little further investigation showed that it is not only
within the limits of possibility, but perfectly feasible,
to exterminate malaria absolutely from the mosquito
end. In the first place, it was quickly found that by
a most merciful squeamishness on the part of the
plasmodium, it could live only in the juices of one
particular genus of mosquito, the Anopheles; and as
nowhere, not even in the most benighted regions of
Jersey, has this genus been found to form more than
about four or five per cent of the total mosquito popu-
lation, this cuts down our problem to one-twentieth of
its apparent original dimensions at once. The ordi-
nary mosquito of commerce (known as Culex) is any

302 PREVENTABLE DISEASES

number of different kinds of a nuisance, but she does
not carry malaria.

Here the trails of the extermination party fork, one
of them taking the perfectly obvious but rather trouble-
some direction of protecting houses and particularly
bedrooms with suitable screens and keeping the inhab-
itants safely behind them from about an hour before
sundown on. By this simple method alone, parties
of explorers, of campers, of railroad-builders going
through swamps, of the laborers on our Panama Canal,
have been enabled to live for weeks and months in
the most malarious regions with perfect impunity, so
long as these precautions were strictly observed. The
first experiment of this sort was carried out by Bignami
upon a group of laborers in the famous, or rather in-
famous, Roman Campagna, whose deadly malarial
fevers have a classic reputation, and has achieved
its latest triumphs in the superb success of Colonel
Gorgas at Panama. While this procedure should never
be neglected, it is obvious that it involves a good deal
of irksome confinement and interferes with freedom
of movement, and it will probably be carried out com-
pletely only under military or official discipline, or in
tropical regions where the risks are so great that its
observance is literally a matter of life or death.

The other division of malaria-hunters pursued the
trail of the Anopheles to her lair. There they discovered
facts which give us practically the whip-hand over
malarial and other tropical fevers whenever we choose
to exercise it. It had long been known that the breeding-
place of mosquitoes was in water ; that their eggs when

MALARIA 803

deposited in water floated upon the surface like tiny
boats, usually glued together into a raft ; that they then
turned into larvae, of which the well-known " wigglers"
in the water-butt or the rain-barrel are familiar ex-
amples ; and that they finally hatched into the complete
insect and rose into the air.

Obviously, there were two points at which the de-
stroyers might strike, the egg and the larvae. It was
first found that, while the eggs required no air for their
development, the larvae wiggled up to the surface and
inhaled it through curious little tubes developed for
this purpose, oddly enough from their tail-ends. If
some kind of film could be spread over the surface of
the water, through which the larvae could not obtain
air, they would suffocate. The well-known property of
oil in " scumming over" water was recalled, two or
three stagnant pools were treated with it, and to the de-
light of the experimenters, not a single larva was able to
develop under the circumstances. Here was insecticide
number one. The cheapest of oils, crude petroleum, if
applied to the pool or marsh in which mosquitoes breed,
will almost completely exterminate them. Scores of
regions and areas to-day, which were once almost un-
inhabitable on account of the plague of mosquitoes,
are now nearly completely free from these pests by
this simple means. An ounce to each fifteen square
feet of water-surface is all that is required, though
the oiling needs to be repeated carefully several times
during the season.

But what of the eggs ? They require no air, and it
was found impossible to poison them without simply

304 PREVENTABLE DISEASES

saturating the water with powerful poisons; but an
unexpected ally was at our hand. It was early noted
that mosquitoes would not breed freely in open rivers
or in large ponds or lakes, but why this should be
the case was a puzzle. One day an enthusiastic mos-
quito-student brought home a number of eggs of
different species, which he had collected from the neigh-
boring marshes, and put them into his laboratory
aquarium for the sake of watching them develop and
identifying their species. The next morning, when he
went to look at them, they had totally disappeared.
Thinking that perhaps the laboratory cat had taken
them, and overlooking a most contented twinkle in
the corner of the eyes of the minnows that inhabited
the aquarium, he went out and collected another
series. This time the minnows were ready for him,
and before his astonished eyes promptly pounced on
the raft of eggs and swallowed them whole. Here was
the answer at once : mosquitoes would not develop
freely where fish had free access; and this fact is our
second most important weapon in the crusade for their
extermination. If the pond be large enough, all that
is necessary is simply to stock it with any of the local
fish, minnows, killies, perch, dace, bass, — and presto !
the mosquitoes practically disappear. If it be near
some larger lake or river containing fish, then a chan-
nel connecting the two, to allow of its stocking, is all
that is required.

On the Hackensack marshes to-day trenches are
cut to let the water out of the tidal pools ; while in
low-lying areas, which cannot be thus drained, the

MALARIA 305

central lowest spot is selected, a barrel is sunk at
this spot, and four or five "killie" fish are placed in
it. Trenches are cut converging into this barrel from
the whole of the area to be drained, and behold, no
more mosquitoes can breed in that area, and, in the
language of the day, "get away with it."

Finally, most consoling of all, it was discovered
that, while the ordinary Culex mosquito can breed,
going through all the stages from the egg to the com-
plete insect, in about fourteen days, so that any
puddle which will remain wet for that length of time,
or even such exceedingly temporary collections of
water as the rain caught in a tomato-can, in an old
rubber boot, in broken crockery, etc., will serve her
for a breeding-place, the Anopheles on the other hand
takes nearly three months for the completion of her
development. So that, while a region might be simply
swarming with ordinary mosquitoes, it would fre-
quently be found that the only places which fulfilled
all the requirements for breeding-homes for the Ano-
pheles, that is, isolation from running water or larger
streams, absence of fish, and persistence for at least
three months continuously, would not exceed five or
six to the square mile. Drain, fill up, or kerosene these
puddles, — for they are often little more than that, —
and you put a stop to the malarial infection of that par-
ticular region. Incredible as it may seem, places in
such a hotbed of fevers as the west coast of Africa,
which have been thoroughly investigated, drained, and
cleaned up by mosquito-brigades, have actually been
freed from further attacks of fever by draining and

306 PREVENTABLE DISEASES

filling not to exceed twenty or thirty of these breeding-
pools.

In short, science is prepared to say to the community :
" I have done my part in the problem of malaria. It is
for you to do the rest." There is literally no neighbor-
hood in the temperate zone, and exceedingly few in
the tropics, which cannot, by intelligent cooperation
and a moderate expense, be absolutely rid first of
malaria, and second of all mosquito-pests. It is only
a question of intelligence, cooperation, and money
The range of flight of the ordinary mosquito is seldom
over two or three hundred yards, save when blown
by the wind, and more commonly not more than as
many feet, and thorough investigation of the ground
within the radius of a quarter of a mile of your house
will practically disclose all the danger you have to
apprehend from mosquitoes. It is a good thing to be-
gin with your own back yard, including the water-
butt, any puddles or open cesspools or cisterns, and
any ornamental water gardens or lily-ponds. These
latter should be stocked with fish or slightly oiled
occasionally. If there be any accumulations of water,
like rain-barrels or cisterns, which cannot be abol-
ished, they should either be kept closely covered or
well screened with mosquito netting.

It might be remarked incidentally in passing, that
the only really dangerous sex in mosquitodom, as
elsewhere, is the female. The male mosquito, if he
were taxed with transmitting malaria, would have a
chance to reecho Adam's cowardly evasion in the
Garden of Eden, " It was the woman that thou gavest

MALARIA 307

me." Both sexes of mosquitoes under ordinary condi-
tions are vegetable feeders, living upon the juices of
plants. But when the female has thrown upon her the
tremendous task of ripening and preparing her eggs
for deposition, she requires a meal of blood — which
may be a comfort to our vegetarian friends, or it may
not. Either she requires a meal of blood to nerve her up
to her criminal deed, or, when she has some real work
to do, she has to have some real food.

The mosquito-brigade have still another method of
checking the spread of malaria, at first sight almost
a whimsical one, — no less than screening the patient.
The mosquito, of course, criminal as she is, does not
hatch the parasites de novo in her own body, but simply
sucks them up in a meal of blood from some previous
victim. Hence by careful screening of every known
case of malaria, mosquitoes are prevented from be-
coming infected and transmitting the disease. In-
stead of the screens protecting the victims from the
mosquitoes, they protect the mosquitoes against the
victim.

This explains why hunters, trappers, and Indians
may range a region for years, without once suffering
from malaria, while as soon as settlers begin to come in
in considerable numbers, it becomes highly malarious.
It had to be infected by the coming of a case of the
disease.

The notorious prevalence of malaria on the frontier
is due to the introduction of the plasmodium into a
region swarming with mosquitoes, where there are few
window-screens or two-story houses.

308 PREVENTABLE DISEASES

No known race has any real immunity against ma-
laria. The negro and other colored races, it is true, are
far less susceptible ; but this we now know applies only
to adults, as the studies of Koch in Africa showed that
a large percentage of negro children had the plasmo-
dium in their blood. No small percentage of them die
of malaria, but those who recover acquire a certain
degree of immunity. Possibly they may be able to
acquire this immunity more easily and with less fatality
than the white race, but this is the extent of their superi-
ority in this regard. The negro races probably represent
the survivors of primitive men, who were too unenter-
prising to get away from the tropics, and have had to
adjust themselves as best they might.

The serious injury wrought in the body by malaria
is a household word, and a matter of painfully familiar
experience. Scarcely an organ in the body escapes
damage, though this may not be discovered till long
after the " fever-and-ague " has been recovered from.

As the parasite breeds in the red cells of the blood,
naturally its first effect is to destroy huge numbers of
these, producing the typical malarial anosmia, or blood-
lessness. Instead of 5,000,000 to the cubic centimetre
of blood the red cells may be reduced to 2,000,000
or even 1,500,000. The breaking down of these red
cells throws their pigment or coloring-matter afloat
in the blood ; and soaking through all the tissues of the
body, this turns a greenish-yellow and gives the well-
known sallow skin and yellowish whites of the eyes of
swamp-dwellers and "river-rats."

The broken-down scraps of the red blood-cells,

MALARIA

309

together with the toxins of the parasite, are carried
to the liver and spleen to be burned up or purified
in such quantities that both become congested and
diseased, causing the familiar "biliousness," so char-
acteristic of malaria.

The spleen often becomes so enormously enlarged
that it can be readily felt with the hand in the left side
below the ribs, so that it is not only relied upon as a
sign of malaria in doubtful cases, but has even received
the popular name of the "ague-cake'* in malarious
districts.

So full is the blood of the parasites, that they may
actually choke up the tiny blood-vessels and capillaries
in various organs, so as to block the circulation and
cause serious and even fatal congestions. Obstruc-
tions of this sort may occur in the brain, the liver, the
coats of the stomach, or intestines, and the kidneys;
and they are the chief cause of the deadly "conges-
tive chills," or pernicious malarial paroxysms, which
we have alluded to.

The kidneys are particularly liable to be attacked
in this way; indeed, one of their involvements is so
serious and fatal in the tropics as to have been given
a separate name, " Blackwater fever," from the quan-
tities of broken-down blood which appear in and
blacken the urine.

The vast majority of attacks of malaria are com-
pletely recovered from, like any other infection, but it
can easily be seen what an injurious effect upon the
system may be produced by successive attacks,
keeping the entire body saturated with the poison;

310 PREVENTABLE DISEASES

while there is serious risk of the parasite sooner or
later finding some weak spot in the body, — kidney,
liver, nervous system, — where its incessant battering
works permanent damage.

How long the infection may lurk in the body is
uncertain ; certainly for months, and possibly for years.
Many cases are on record which had typical chills
and fever, with abundance of plasmodia in the blood,
years after leaving the tropics or other malarious dis-
tricts ; but there is often the possibility of a recent re-
infection.

Altogether, malaria is a remarkably bad citizen in
any community, and its stamping-out is well worth all
it costs.

CHAPTER XIV

RHEUMATISM: WHAT rr is, AND PARTICULARLY WHAT
IT is N'T

"TITTHAT 'S in a name ? All the aches and pains
T V that came out of Pandora's box, if the name
happens to be rheumatism. It is a term of wondrous
elasticity. It will cover every imaginable twinge in any
and every region of ^the body — and explain^ none of
them. It is a name that means just nothing, and yet
it is in every man's vocabulary, from proudest prince
to dullest peasant. Its derivative meaning is little short
of an absurdity in its inappropriateness, from the Greek
reuma (a flowing), hence, a cold or catarrh. It is still
preserved for us in the familiar " salt rheum " (eczema)
and "rheum of the eyes" of our rural districts. But
this very indefiniteness, absurdity if you will, is a
comfort both to the sufferer and to the physician.
Moreover, incidentally, to paraphrase Portia's famous
plea, —

It blesseth him that has and him that treats ;

'T is mightier than the mightiest.

It doth fit the throned monarch closer than his crown.

To the patient it is a satisfying diagnosis and satis-
factory explanation in one ; to the doctor, a great saving
of brain-fag. When we call a disease rheumatism, we
know what to give for it — even if we don't know what
it is. As the old German distich runs, —

312 PREVENTABLE DISEASES

Was man kann nicht erkennen,
Muss er Rheumatismus nennen.1

However, in spite of the confusion produced by
this wholesale and indiscriminate application of the
term to a host of widely different, painful conditions,
many of which have little else in common save that they
hurt and can be covered by this charitable name-blanket,
a few definite facts are crystallizing here and there out
of the chaos. The first is, that out of this swarm of
different conditions there can be isolated one large
and important central group which has the characters
of a well-defined and constant disease-entity. This is
the disease known popularly as rheumatic fever, and
technically as acute rheumatism or acute articular
rheumatism. In fact, the commonest division is to
separate the "rheumatisms" into two great groups:
acute, covering the "fever" form, and chronic, con-
taining all the others. From a purely scientific point
of view, this classification has rather an undesirable
degree of resemblance to General Grant's famous
division of all music into two tunes : one of which was
Old Hundred, and the other was n't. But for practical
purposes it has certain merits and may pass.

Every one has seen, or known, or had, the acute
articular form of rheumatism, and when once seen there
is no difficulty in recognizing it again. It is one of the
most striking and most abominable of disease-pictures,
beginning with high fever and headache, then tender-
ness, quickly increasing to extreme sensitiveness in
one or more of the larger joints, followed by drenching
1 What one cannot recognize he must call rheumatism.

RHEUMATISM 313

sweats of penetrating acid odor. The joint attacked
becomes red, swollen, and glossy, so tender that merely
pointing a finger at it will send a twinge of agony
through the entire body, and the patient lies rigid and
cramped for fear of the agony caused by the slightest
movement. The tongue becomes coated and foul, the
blood-cells are rapidly broken down, and the victim
becomes ashy pale. He is worn out with pain and fever,
yet afraid to fall asleep for fear of unconsciously moving
the inflamed joint and waking in tortures; and alto-
gether is about as acutely uncomfortable and com-
pletely miserable as any human being can well be made
in so short a time.

Fortunately, as with its twin brother, the grip, the
bark of rheumatism is far worse than its bite ; and a
striking feature of the disease is its low fatality, es-
pecially when contrasted with the fury of its onslaught
and the profoundness of the prostration which it pro-
duces. Though it will torture its victim almost to
the limits of his endurance for days and even weeks at
a stretch, it seldom kills directly. Its chief danger
lies in the legacies which it bequeaths. Though, like
nearly all fevers, it is self-limited, tends to run its
course and subside when the body has manufactured
an antitoxin in sufficient amounts, it is unique in an-
other respect, and that is in the extraordinary variabil-
ity of the length of its "course." This may range any-
where from ten days to as many weeks, the " average
expectation of life" being about six weeks. The ago-
nizing intensity of the pain and acute edge of the dis-
comfort usually subside in from five to fifteen days,

314 PREVENTABLE DISEASES

especially under competent care. When the tempera-
ture falls, the drenching sweats cease, the joints be-
come less exquisitely painful, and the patient gradu-
ally begins to pull himself together and to feel as if life
were once more worth living. He is not yet out of the
woods, however, for while the pain is subsiding in the
joints which have been first attacked, another joint
may suddenly flare up within ten or twelve hours, and
the whole distressing process be repeated, though
usually on a somewhat milder and shorter scale. This
uncertainty as to how many joints in the body may be
attacked, is, in fact, one of the chief elements in making
the duration of the disease so irregular and incalcu-
lable.

Even when the frank and open progress of the dis-
ease through the joints of the body has come to an end,
the enemy is still lying in wait and reserving his most
deadly assault. Distressing and crippling as are the
effects of rheumatism upon the joints and tendons,
its most deadly and permanent damage is wrought
upon the heart. Fortunately, this vital organ is not
attacked in more than about half the cases of acute
rheumatism, and in probably not more than one-third
of these are the changes produced either serious or
permanent, especially if the case be carefully watched
and managed. But it is not too much to say that, of
all cases of serious or "organic" heart disease, rheu-
matism is probably responsible for from fifty to seventy
per cent. The same germ or toxin which produces the
striking inflammatory changes in the joints may be
carried in the blood to the heart, and there attack either

RHEUMATISM 315

the lining and valves of the heart (endocardium),
which is commonest, or the covering of the heart (peri-
cardium), or the heart-muscle. So intense is the in-
flammation, that parts of the valves may be literally
eaten away by ulceration, and when these ulcers heal
with formation of scar-tissue as everywhere else in the
body, the flaps of the valves may be either tied together
or pulled out of shape, so that they can no longer pro-
perly close the openings of the heart-pump. This con-
dition, or some modification of it, is what we usually
mean when we speak of "heart disease," or "organic
heart disease." The, effect upon the heart-pump is
similar to that which would be produced by cutting
or twisting the valve in the "bucket" of a pump or
in a bulb syringe.

In severe cases of rheumatism the heart may be
attacked within the first few days of the disease, but
usually it is not involved until after the trouble in the
joints has begun to subside ; and no patient should be
considered safe from this danger until at least six
weeks have elapsed from the beginning of the fever.
The few cases (not to exceed one or two per cent) of
rheumatic fever which go rapidly on to a fatal termi-
nation, usually die from this inflammation of the heart,
technically known as endocarditis. The best way of
preventing this serious complication and of keeping
it within moderate limits, if it occurs, is absolute rest
in bed, until the danger period is completely passed.

Now comes another redeeming feature of this trouble-
some disease, and that is the comparatively small per-
manent effects which it produces upon the joints in the

316 PREVENTABLE DISEASES

way of crippling, or even stiffening. To gaze upon a
rheumatic knee-joint, for instance, in the height of
the attack, — swollen to the size of a hornet's nest,
hot, red, throbbing with agony, and looking as if it
were on the point of bursting, — one would almost
despair of saving the joint, and the best one would feel
entitled to expect would be a roughening of its sur-
faces and a permanent stiffening of its movements.

On the contrary, when once the fury of the attack
has passed its climax, especially if another joint should
become involved, the whole picture changes as if by
magic. The pain fades away to one-fifth of its former
intensity within twenty-four, or even within twelve
hours ; three-fourths of the swelling follows suit in forty-
eight hours; and within three or four days' time the
patient is moving the joint with comparative ease and
comfort. After he gets up at the end of his six weeks,
the knee, though still weak and stiff and sore, within a
few weeks' time "limbers up" completely, and usu-
ally becomes practically as good as ever. In short, the
violence and swiftness of the onset are only matched
by the rapidity and completeness of the retreat. It
would probably be safe to say that not more than one
joint in fifty, attacked by rheumatism, is left in any way
permanently the worse.

But, alas ! to counterbalance this mercifulness in the
matter of permanent damage, unlike most other infec-
tions, one attack of rheumatic fever, so far from pro-
tecting against another, renders both the individual and
the joint more liable to other attacks. The historic
motto of the British in the War of 1812 might be para-

RHEUMATISM 317

phrased into, " Once rheumatic, always rheumatic."
The disease appears to be lost to all sense of decency
and reason ; and to such unprincipled lengths may it go,
that I have actually known one luckless individual who
had the unenviable record of seventeen separate and
successive attacks of rheumatic fever. As he expressed
it, he had "had rheumatism every spring but two for
nineteen years past." Yet only one ankle-joint was
appreciably the worse for this terrific experience.

Obviously, the picture of acute rheumatism carries
upon its face a strong suggestion of its real nature and
causation. The highy temperature, the headache, the
sweats, the fierce attack and rapid decline, the self-
limited course, the tendency to spread from one joint
to another, from the joints to the heart, from the heart
to the lungs and the kidneys, all stamp it unmistakably
as an infection, a fever. On the other hand, there are
two rather important elements lacking in the infection-
picture: one, that, although it does at times occur in
epidemics, it is very seldom transmitted to others ; the
other, that one attack does not produce immunity or
protect against another. The majority of experts are
now practically agreed that acute rheumatism, or rheu-
matic fever, is probably due to the invasion of the sys-
tem by some microorganism or germ. When, however,
we come to fixing upon the particular bacillus, or micro-
coccus, there is a wide divergence of opinion, some six
or seven different eminent investigators having each his
favorite candidate for the doubtful honor. In fact, it is
our inability as yet positively to identify and agree upon
the causal germ that makes our knowledge of the entire

318 PREVENTABLE DISEASES

subject still so regrettably vague, and renders either a
definite classification or successful treatment so difficult.
The attitude of the most careful and experienced
physicians and broad-minded bacteriologists may be
roughly summed up in the statement that acute rheuma-
tism is probably due to some germ or germs, but that the
question is still open which particular germ is at fault,
and even whether the group of symptoms which we call
rheumatism may not possibly be produced by a num-
ber of different organisms, acting upon a particular
type of constitution or susceptibility. There is no diffi-
culty in finding germs of all sorts, principally micro-
cocci, in the blood, in the tissues about the joints, and
on the heart-valves of patients with rheumatism, and
these germs, when injected into animals, will not in-
frequently produce fever and inflammatory changes
in the joints, roughly resembling rheumatism. But the
difficulty so far has been, first, that these organisms are
of several different kinds and distinct species; and
second, and even more important, that almost any of
the organisms of the common infectious diseases are
capable at times of producing inflammation of the joints
and tendons. For instance, the third commonest point
of attack of the tubercle bacillus, after the lungs and the
glands, is the bones and joints, as illustrated in the
sadly familiar " white-swelling of the knee " and hip-
joint disease. All the so-called septic organisms, which
produce suppuration and blood-poisoning in wounds
and surgery, may, and very frequently do, attack the
joints ; while nearly all the common infections, such as
typhoid, scarlet fever, pneumonia, and even measles,

RHEUMATISM 319

influenza, and tonsillitis, may be followed by severe
joint symptoms.

In fact, we are coming to recognize that diseases of
the joints, like diseases of the nervous system, are among
the frequent results of any and all of the acute infec-
tious diseases or fevers ; and we now trace from fifty to
seventy-five per cent of both joint troubles and degener-
ations of the nervous system to this cause. Two-thirds,
for instance, of our cases of hip-joint disease and of
spinal disease (caries) are due to tuberculosis.

The puzzling problem now before pathologists is the
sorting out of these innumerable forms of joint in-
flammations and the^ splitting off of those which are
clearly due to certain specific diseases, from the great,
central group of true rheumatism. Most of these joint
inflammations which are due to recognized germs, such
as the pus-organisms of surgical fevers, tuberculosis,
and typhoid, differ from true rheumatism in that they
go on to suppuration (formation of "matter") and
permanently cripple the joint to a greater or less degree.
So that there is probably a germ or group of germs which
produces the swift attack and rapid subsidence and
other characteristic features of true rheumatism, even
though we have not yet succeeded in sorting them out
of the swarm. So confident do we feel of this, that al-
though, as will be shown, there are probably other
factors involved, such as exposure, housing, occupation,
food, and heredity, yet the best thought of the profes-
sion is practically agreed that none of these would
alone produce the disease, but that they are only ac-
cessory causes plus the micrococcus. In practically

320 PREVENTABLE DISEASES

all our modern textbooks of medicine, rheumatism is
included under the head of infections.

This theory of causation, confessedly provisional and
imperfect as it is, helps us to harmonize the other known
facts about the disease; it has already greatly improved
our treatment and given us a foothold for attacking the
problem of prevention. For instance, it has long been
known that rheumatism was very apt to follow tonsil-
litis or other forms of sore throat; indeed, many of the
earlier authorities put down tonsillitis as one of the
great group of "rheumatic" disturbances, and per-
sons of rheumatic family tendency were supposed to
have tonsillitis in childhood and rheumatism in later
life. Not more than ten or fifteen per cent of all cases
gave a history of tonsillitis ; but since we have broadened
our conception of infection and begun to inquire, not
merely for symptoms of tonsillitis, but also for those of
influenza, " common colds," measles, whooping-cough,
and the like, we reach the most significant result of
finding that forty to sixty per cent of our cases of rheu-
matism have been preceded, anywhere from one to
three weeks before, by an attack of some sort of " cold,"
sore throat, oatarrhal fever, cough, bronchitis, or other
group of disturbances due to a mild infection. Fur-
ther, it has long been notorious that when a rheumatic
individual " catches cold " it is exceedingly apt to " set-
tle in the joints," and, if these cases happen to come
under the eye of a physician, they are recognized as
secondary attacks of true rheumatism. In other words,
the " cold" may simply be a second dose of the same
germ which caused the primary attack of rheumatism.

RHEUMATISM 321

This brings us to the widespread article of popular
belief that rheumatism is most commonly due to cold,
exposure, chill, or damp. Much of this is found on in-
vestigation to be due to the well-known historic confu-
sion between " cold," in the sense of exposure to cold
air, and "cold," in the sense of a catarrh or influenza,
with running at the nose, coughing, sore throat, and
fever, a group of symptoms now clearly recognized to
be due to an infection. In short, the vast majority of
common colds are unmistakably infections, and spread
from one victim to another, and this is the type of
" cold "which causes the majority of rheumatic attacks.

The chill, which any one who is " coming down " with
a cold experiences, and usually refers to a draft or a cold
room, is, in nine cases out of ten, the rigor which pre-
cedes the fever, and has nothing whatever to do with
the external temperature. The large majority of our
cases of rheumatism can give no clear or convincing his-
tory of exposure to wet, cold, or damp. But popular
impression is seldom entirely mistaken, and there can
be no question that, given the presence of the infectious
germ, a prolonged exposure to cold, and particularly
to wet, will often prove to be the last straw which will
break down the patient's power of resistance, and de-
termine an attack of rheumatism.

This climatic influence, however, is probably not re-
sponsible for more than fifteen or twenty per cent of all
cases, and, popular impression to the contrary notwith-
standing, the liability of outdoor workers who are sub-
ject to severe exposure, such as lumbermen, fishermen,
and sailors, is only slightly greater than that of indoor

322 PREVENTABLE DISEASES

workers. The highest susceptibility, in fact, not merely
to the disease, but also to the development of serious
heart involvements, is found among domestic servants,
particularly servant girls, agricultural laborers and their
families (in districts where wages are low and cottages
bad) , and slum-dwellers ; in fact, those classes which are
underfed, overworked, badly housed, and crowded to-
gether. Diet has exceeding little to do with the disease,
and, so far from meat or high living of any sort pre-
disposing to it, it is most common and most serious in
precisely those classes which get least meat or luxuries
of any sort, and are from stern necessity compelled to
live upon a diet of cereals, potatoes, cheap fats, and
coarse vegetables.

Even its relations to the weather and seasons support
the infection theory. Its seasonal occurrence is very
similar to that of pneumonia, — rarest in summer, com-
monest in winter, the highest percentage of cases oc-
curring in the late fall and in the early spring ; in other
words, just at those times when people are first begin-
ning to shut themselves up for the winter, light fires, and
close windows, and at the end of their long period of
winter imprisonment, when both their resisting power
has been reduced to the lowest ebb in the year and in-
fections of all sorts have had their most favorable con-
ditions of growth for months.

The epidemics of rheumatism, which occasionally
occur, probably follow epidemics of influenza, tonsil-
litis, or other mild infections, and instances of two or
more cases of rheumatism in one family or household
are most rationally explained as due to the spread of the

RHEUMATISM 323

precedent infection from one member of the family to
the other. Instances of the direct transmission of the
disease from one patient to another are exceedingly rare.

Our view of the infectious causation of rheumatism,
vague as it is, has given us already our first intelligent
prospect of prevention. Whatever may be the character
of a germ or germs, the vast majority of them agree in
making the nose and throat their first point of attack and
of entry into the system. Hence, vigorous antiseptic
and other rational treatment of all acute disturbances
of the nose and throat, however slight, will prove a valu-
able preventive and diminisher of the percentage of
rheumatism. This simply emphasizes again the truth
and importance of the dictum of modern medicine,
"Never neglect a cold," since we are already able to
trace, not merely rheumatism, but from two-thirds to
three-fourths of our cases of heart disease, of kidney
trouble, and of inflammations of the nervous system, to
those mild infections which we term "colds," or to
other definite infectious diseases.

Not only is this good a priori reasoning, but it has
been demonstrated in practice. One of our largest
United States army posts had acquired an unenviable
reputation from the amount of rheumatism occurring
in the troops stationed there. A new surgeon coming
to take charge of the post set about investigating the
cause of this state of affairs, and came to the conclusion
that the disease began as, or closely followed, tonsillitis
and other forms of sore throat. He accordingly saw to
it that every case of tonsillitis, of cold in the head, or
sore throat was vigorously treated with local germicides

324 PREVENTABLE DISEASES

and with intestinal antiseptics and laxatives, until it
was completely cured ; with the result that in less than
a year he succeeded in lowering the percentage of cases
of rheumatism per company nearly sixty per cent.

At some of our large health-resorts, where great num-
bers of cases of rheumatism are treated, it has been dis-
covered that if a case of common cold, or tonsillitis, hap-
pens to come into the establishment, and runs through
the inmates, nearly half of the rheumatic patients at-
tacked will have a relapse or new seizure of their rheu-
matism. Accordingly, a rigorous and hawk-like watch is
kept for every possible case of cold, tonsillitis, or sore
throat entering the house ; the patient is promptly iso-
lated and treated on rigidly antiseptic principles, with
the result that epidemics of relapses of rheumatism in
the inmates have greatly diminished in frequency.

If every case of cold or sore .throat were promptly and
thoroughly treated with antiseptic sprays and washes
such as any competent physician can direct his patients
to keep in the house, in readiness for such an emer-
gency, combined with laxatives and intestinal antisep-
tic treatment, and, above all, with rest in bed as long as
any rise of temperature is present, there would be a
marked diminution in both the frequency and the
severity of rheumatism. If to this were added an
abundant and nutritious dietary, good ventilation
and pure air, an avoidance of overwork and over-
strain, we should soon begin to get the better of this
distressing disease. In fact, while positive data are
lacking, on account of the small fatality of rheumatism
and its consequent infrequent appearance among the

RHEUMATISM 325

causes of death in our vital statistics, yet it is the almost
unanimous opinion of physicians of experience that the
disease is distinctly diminishing, as a result of the marked
improvement in food, housing, wages, and living con-
ditions generally, which modern civilization has already
brought about.

So much for acute rheumatism. Vague and un-
satisfactory as is our knowledge of it, it is, unfor-
tunately, clearness and precision itself when con-
trasted with the welter of confusion and fog which
covers our ideas about the chronic variety. The catho-
licity of the term is something incredible. Every chronic
pain and twinge, from corns to locomotor ataxia, and
from stone-in-the-kidney to tic-douloureux, has been
put down as " rheumatism." It is little better than a
diagnostic garbage-dump or dust-heap, where can be
shot down all kinds of vague and wandering pains in
joints, bones, muscles, and nerves, which have no
visible or readily ascertainable cause. Probably at
least half of all the discomforts which are put down as
" rheumatism " of the ankle, the elbow, the shoulder,
are not rheumatism at all, in any true or reasonable
sense of the term, but merely painful symptoms due to
other perfectly definite disease conditions of every im-
aginable sort. The remaining half may be divided into
two great groups of nearly equal size. One of these,
like acute rheumatism, is closely related to, and prob-
ably caused by, the attack of acute infections of milder
character, falling upon less favorable soil. The other
is of a vaguer type and is due, probably, to the accumu-
lation of poisonous waste-products in the tissues, set-

326 PREVENTABLE DISEASES

ting up irritative and even inflammatory changes in
nerve, muscle, and joint. Either of these may be made
worse by exposure to cold or changes in the weather.
In fact, this is the type of rheumatism which has such
a wide reputation as a barometer and weather prophet,
second only to that of the United States Signal Service.
When you " feel it in your bones," you know it is going
to snow, or to rain, or to clear up, or become cloudy,
or whatever else may happen to follow the sensation,
merely because all poisoned and irritated nerves are
more sensitive to changes in temperature, wind-direc-
tion, moisture, and electric tension, than sound and
normal ones. The change in the weather does not
cause the rheumatism. It is the rheumatism that en-
ables us to predict the change in the weather, though
we have no clear idea what that change will be.

Probably the only statement of wide application that
can be made in regard to the nature of chronic rheu-
matism is that a very considerable percentage of it is
due to the accumulation of poisons (toxins) in the
nerves supplying joints and muscles, setting up an ir-
ritation (neurotoxis) , or, in extreme cases, an inflam-
mation of the nerve (neuritis), which may even go on
to partial paralysis, with wasting of the muscles sup-
plied. The same broad principles of causation and pre-
vention, therefore, apply here as in acute rheumatism.

The most important single fact for rheumatics of all
sorts, whether acute or chronic, to remember is that
they must avoid exposure to colds, in the sense of in-
fections of all sorts, as they would a pestilence; that
they must eat plenty of rich, sound, nourishing food ;

RHEUMATISM 327

live in well-ventilated rooms ; take plenty of exercise in
the open air, to burn up any waste poisons that may be
accumulating in the tissues ; dress lightly but warmly
(there is no special virtue in flannels), and treat every
cold or mild infection which they may be unfortunate
enough to catch, according to the strictest rigor of the
antiseptic law.

The influence of diet in chronic rheumatism is almost
as slight as in the acute form. Persons past middle age
who can afford to indulge their appetites and are in-
clined to eat and drink more than is good for tljem, and,
what is far more important, to exercise much less, may
so embarrass their liver and kidneys as to create accumu-
lations of waste products in the blood sufficient to cause
rheumatic twinges. The vast majority, however, of the
sufferers from chronic rheumatism, like those from the
acute form, are underfed rather than overfed, and a
liberal and abundant dietary, including plenty of red
meats, eggs, fresh butter, green vegetables, and fresh
fruits, will improve their nutrition and diminish their
tendency to the attacks.

There appears to be absolutely no rational founda-
tion for the popular belief that red meats cause rheu-
matism, either from the point of view of practical
experience, or from that of chemical composition. We
now know that white meats of all sorts are quite as rich
in those elements known as the purin bodies, or uric-
acid group, as red meats, and many of them much
richer. It may be said in passing, that this last-men-
tioned bugbear of our diet-reformers is now believed to
•have nothing whatever to do with rheumatism, and

328 PREVENTABLE DISEASES

probably very little with gout, and that the ravings of
Haig and the Uric-Acid School generally are now thor-
oughly discredited. Certainly, whenever you see any
remedy or any method of treatment vaunted as a cure
for rheumatism, by neutralizing or washing out uric
acid, you may safely set it down as a fraud.

One rather curious and unexpected fact should,
however, be mentioned in regard to the relation of diet
to rheumatism, and that is that many rheumatic patients
have a peculiar susceptibility to some one article of food.
This may be a perfectly harmless and wholesome thing
for the vast majority of the species, but to this individual
it acts as a poison and will promptly produce pains in
the joints, redness, and even swelling, sometimes ac-
companied by a rash and severe disturbances of the di-
gestive tract. The commonest offenders form a curious
group in their apparent harmlessness, headed as they
are by strawberries, followed by raspberries, cherries,
bananas, oranges ; then clams, crabs, and oysters ; then
cheese, especially overripe kinds ; and finally, but very
rarely, certain meats, like mutton and beef. What is
the cause of this curious susceptibility we do not know,
but it not infrequently occurs with this group of foods
in rheumatics and also in asthmatics.

Both rheumatics and asthmatics are also subject to
attacks of urticaria or " hives " (nettle-rash) , from these
and other special articles of diet.

As to principles of treatment in a disease of so varied
and indefinite a character, due to such a multitude of
causes, obviously nothing can be said except in the
broadest and sketchiest of outline. The prevailing.

RHEUMATISM 329

tendency is, for the acute form, rest in bed, the first
and most important, also the second, the third, and
the last element in the treatment. This will do more to
diminish the severity of the attack and prevent the oc-
currence of heart and other complications than any
other single procedure.

After this has been secured, the usual plan is to as-
sist nature in the elimination of the toxins by alka-
lies, alkaline mineral waters, and other laxatives; to
relieve the pain, promote the comfort, and improve the
rest of the patient by a variety of harmless nerve-
deadeners or pain-relievers, chief among which are the
salicylates, aspirin, and the milder coal-tar products.
By a judicious use of these in competent hands the pain
and distress of the disease can be very greatly re-
lieved, but it has not been found that its duration is
much shortened thereby, or even that the danger of
heart and other complication is greatly lessened. The
agony of the inflamed joints may be much diminished
by swathing in cotton-wool and flannel bandages, or
in cloths wrung out of hot alkalies covered with oiled
silk, or by light bandages kept saturated with some
evaporating lotion containing alcohol. As soon as the
fever has subsided, then hot baths and gentle massage
of the affected joints give great relief and hasten the
cure. But, when all is said and done, the most import-
ant curative element, as has already been intimated, is
six weeks in bed.

In the chronic form the same remedies to relieve the
pain are sometimes useful, but very much less effective,
and often of little or no value. Dry heat, moist heat,

330 PREVENTABLE DISEASES

gentle massage, and prolonged baking in special metal
ovens, will often give much relief. Liniments of all
sorts, from spavin cures to skunk oil, are chiefly of
value in proportion to the amount of friction and mas-
sage administered when they are rubbed in.

In short, there is no disease under heaven in which
so much depends upon a careful study of each individ-
ual case and adaptation of treatment to it personally,
according to its cause and the patient in whom it oc-
curs. Rheumatism, unfortunately, does tend to " run
in families." Apparently some peculiar susceptibility
of the nervous system to influences which would be
comparatively harmless to normal nerves and cells
is capable of being inherited. But this inheritance is
almost invariably " recessive," in Mendelian terms,
and a majority of the children of even the most rheu-
matic parent may entirely escape the disease, especially
if they live rationally and vigorously, feed themselves
abundantly, and avoid overwork and overcrowding.

CHAPTER XV

GERM-FOES THAT FOLLOW THE KNIFE, OR DEATH
UNDER THE FINGER-NAIL

OUR principal dread of a wound is from fear that
it may fester instead of healing quickly. We don't
exactly enjoy being shot, or stabbed, or scratched , though,
as a matter of fact, in what Mulvaney calls the "fog
av fightin"' we hardly notice such trifles unless im-
mediately disabling. But our greatest fear after the
bleeding has stopped is lest blood-poisoning may set
in. And we do well to dread it, for in the olden days, —
that is, barely fifty years ago, — in wounds of any size
or seriousness, two-thirds of the risk remained to be
run after the bleeding had been stopped and the band-
ages put on. Nowadays the danger is only a fraction of
one per cent, but till half a century ago every wound
was expected to form "matter" or pus in the process
of healing, as a matter of course. Most of us can recall
the favorite and brilliant repartee of our boyhood days
in answer to the inquisitive query, " What's the mat-
ter ? " " Nuthin' : it has n't come to matter yet. It's
only a fresh cut ! "

Even surgeons thought it a necessary part of the pro-
cess of healing, and the approving term " laudable pus "
was applied to a soft, creamy discharge, without either
offensive odor or tinge of blood, upon the surfaces of the
healing wound; and the hospital records of that day

332 PREVENTABLE DISEASES

noted with satisfaction that, after an operation, "sup-
puration was established." So strongly was this idea
intrenched, that a free discharge or outpouring of some
sort was necessary to the proper healing of the wound,
that in the Middle Ages it was regarded as exceedingly
dangerous to permit wounds to close too quickly.
Wounds that had partially united were actually torn
apart, and liquids like oil and wine and strong acids,
which tended to keep them from closing and to set up
suppuration, were actually poured into them; and in
some instances their sides were actually burned with
hot irons. There was a solid basis of reason under-
lying even these extraordinary methods, viz., the " rule
of thumb " observation, handed down from one gener-
ation to another, that wounds that discharged freely
and " sweetly," while they were slow in healing and
left disfiguring scars, usually did not give rise to serious
or fatal attacks of blood-poison or wound-fever. And
of two evils they chose the less. Plenty of pus and a big
ugly scar in preference to an attack of dangerous blood-
poisoning. Even if it did n't kill you, it might easily
cripple you for life by involving a joint. The trouble
was with their logic, or rather with their premises.
They were firmly convinced that the danger came from
ivithin, that there was a sort of morbid humor which
must be allowed to escape, or it would be dammed up
in the system with disastrous results.

One day a brilliant skeptic by the name of Lister
(who is still living) took it into his head that perhaps
the fathers of surgery and their generations of imitators
might have been wrong. He tried the experiment, shut

DEATH UNDER THE FINGER-NAIL 333

germs out of his wounds, and behold, antiseptic sur-
gery, with all its magnificent line of triumphs, was born !

Now a single drop of pus in an operation wound is
as deep a disgrace as a bedbug on the pillow of a model
housekeeper, and calls for as vigorous an overhauling
of equipment, from cellar to skylight; while a second
drop means a commission of inquiry and a drumhead
court-martial. This is the secret of the advances of
modern surgery, — not that our surgeons are any more
skillful with the knife, but that they can enter cavities
like those of the skull, the spinal cord, the abdomen,
and the chest, remove what is necessary, and get out
again with almost perfect safety ; whereas these cavities
were absolutely forbidden ground to their forefathers,
on account of the twenty, forty, yes, seventy per cent
death risk from suppuration and blood-poison.

The triumphs of antisepsis and asepsis, or keeping
the " bugs " out of the cuts, have been illustrated scores
of times already by abler pens, and are a household
word, but certain of its practical appliances in the
wounds and scratches and trifling injuries of every-day
life are not yet so thoroughly familiar as they should
be. When once we know who our wound-enemies are,
whence they came, and how they are carried, the fate
of the battle is practically in our own hands.

Like most disease-germs our wound-infection foes
are literally " they of our own household." They don't
pounce down upon us from the trees, or lie in wait for
us in the thickets, or creep in the grass, or grow in the
soil, or swarm in our food. They live and can live
only within the shelter of our own bodies, where it is

334 PREVENTABLE DISEASES

warm and moist and comfortable. This is one great (in
the expressive vernacular) " cinch " that we have on
the vast majority of disease-germs, whether medical
or surgical, that they do not flourish and breed outside
of the body, or of houses closed and warm; and this
grip can be improved, with skill and determination,
into a veritable strangle-hold on most of them. In the
language of biology, most of them have become
"adapted to their environment" so closely that they
can scarcely flourish and breed anywhere outside of the
warm, moist, fertile soil of a living body, and many
of them cannot even live long at temperatures more
than ten degrees above or fifteen degrees below that
of the body. At all events, so poorly are these pus-
germs able to preserve their vigor and power of attack,
not merely outside of the human body, but outside of
some wound or sore spot, that it is practically certain
that eight-tenths of all cases of wound-infection or
blood-poisoning come directly from some previous
festering wound, sore, ulcer, scab, boil, or pimple, in or
on some other human being or animal. Practically
whenever we get pus in a wound in a hospital, we
insist upon finding the precise previous case of pus
from which that originated, and seldom is our search
unsuccessful. If we kept not only our wounds surgically
clean, but our gums, noses, throats, skins, and finger-
nails, and burned and sterilized everything that came
in contact with a sore, pustule, or scab, we should wipe
out nine-tenths of our cases of wound-infection and
suppuration; in fact, practically all of them, except
such small percentage as may come from contact with

DEATH UNDER THE FINGER-NAIL 335

infections in animals. This is the reason why, up to
half a century ago, by a strange paradox hospitals were
among the most dangerous places to perform opera-
tions in, on account of the abundance of wounds or
sores always present for the pus-germs to breed in,
and the fact that out of fifty or more wound-cases,
there was practically certain to be one or two infected
ones to poison the whole lot.

Surgeons, ignorant of antisepsis, and careless nurses,
spread the infection along, until in some instances it
reached a virulence which burst into the dreaded
" hospital gangrene." This dread disease was the
scourge of all hospitals, especially military ones, all
over the civilized world, as recently as our War of Se-
cession. In some wards of our military hospitals, from
thirty to fifty per cent of all the wounded received were
attacked, and over five thousand cases were formally
reported during the war, of which nearly fifty per cent
died. This plague was born solely of those two great
mothers of evils, ignorance and dirt, and is to-day, in
civilized lands, as extinct as the dodo. Then the dread
that the community had of hospitals, as places that
" help the poor to die," in Browning's phrase, had a
certain amount of foundation ; and cases operated upon
in a farmhouse kitchen, where no one in the family
happened to have had a boil or a catarrh or a fester-
ing cut within a month or so, and where the knife hap-
pened to be clean or new, would recover with less sup-
puration than hospital cases. Nowadays, from inces-
sant and eternal vigilance, a hospital is surgically the
cleanest and safest place in the world for an operation,

336 PREVENTABLE DISEASES

so that most surgeons decline to operate outside of
one, except in emergencies; and some will not even
operate except in one with which they are personally
connected, so that they know every step in the process
of protection.

It was this terrible risk of the surgeon carrying
infection from one case to another, that made the coro-
ner of London declare, barely sixty years ago, that he
would hold an inquest upon the next case of death after
ovariotomy that was reported to him, on account of
the fearful pus-mortality that followed this serious
operation, which now has a possible death-rate from
all causes connected with the operation of only a frac-
tion of one per cent.

The brusque reply is still remembered ofLawson
Tait, the great English ovariotomist, to a distinguished
German colleague, who had inquired the secret of his
then marvelously low death-rate : after a glance at the
bands of mourning on the ends of the other's fingers, he
said, " I keep my finger-nails clean, sir ! " There was
sadly too much truth in the saying of another eminent
surgeon, that in the pre-Listerian days many a poor
woman's death warrant was written under the finger-
nails of her surgeon. This reproach has been wiped
out, thank Heaven! but the labor, pains, and persist-
ence after heart-breaking failures which it took to do
it ! Never was there a more vivid illustration of the
declaration that genius is the capacity for taking pains,
than antiseptic surgery ! Not a loophole must be left
unstopped, not a possibility unconsidered, not a thing
in, or about, or connected with, the operating-room left

DEATH UNDER THE FINGER-NAIL 337

unsterilized, except the patient and the surgeon;
and these are brought as near to it as is possible
without danger to life.

In the first place, the operating-room itself must be
like a bath room, or, more accurately, the inside of a
cistern. Walls, floor, and ceiling are all waterproof and
capable of being washed down with a hose. There must
be no casings or cornices of any sort to catch dust;
and in the best appointed hospitals no one is per-
mitted to enter, under any pretext, whose hands and
garments have not been sterilized.

In the second place, everything that is brought into
the room for use in, "or during, the operation, is first
thoroughly sterilized. The knives, instruments, and
other operative objects are sterilized by boiling, or by
the use of superheated steam ; and the towels, dressings,
bandages, sheets, etc., by boiling, baking, or super-
heated steam. Then begins the preparation of the sur-
geon and the nurse. Dressing-rooms are provided, in
which the outer garments are removed, and the hands
given an ordinary wash. Then the scrubbing-room is
entered, where, at a series of basins provided with
running hot and cold water, whose faucets are turned
by pressure with the foot so as to avoid any necessity
for touching them with the hand, the hands are
thoroughly scrubbed with hot water, boiled soap, and
a boiled nail-brush. Then they are plunged into, and
thoroughly soaked in, some strong antiseptic solution,
then washed again; then plunged into another anti-
septic solution, containing some fat solvent like ether
or alcohol, to wash off any dirt that may have been pro-

338 PREVENTABLE DISEASES

tected by the natural oil of the skin. Then they are
thoroughly scrubbed with soap and hot water again, to
remove all traces of the antiseptics, most of which are
irritating to wounded tissues ; then washed in absolute
alcohol, then in boiled or distilled water. Then the
nurse, whose hands are already sterilized, takes out
of the original package in which it came from the
sterilizing oven, a linen surgical gown or suit which
covers the operator from neck to toes. A sterilized
linen or cotton cap is placed upon his head and pulled
down so that the scales or germs of any sort may not
fall into the wound. Some surgeons of stout and com-
fortable habit, who are apt to perspire in the high tem-
perature of an operating-room, will tie a band of gauze
around their foreheads, to prevent any unexpected
drops of perspiration from falling into the wound;
while some purists muffle up the mouth and lower part
of the face lightly in a similar comforter.

You would think that by this time the hands were
clean enough to go anywhere with safety, but no risks
are going to be taken. A pair of rubber or cotton
gloves, the former taken right out of a strong antiseptic
solution, the latter out of the sterilizing oven, are pulled
carefully on by the nurse. Holding his sacred hands
spread out rigidly before him, like the front paws of
a kangaroo, the surgeon carefully edges his way into the
operating-room, waiting for any doors that he may have
to pass through to be opened by the nurse, or awk-
wardly pushing them with his elbow. In that attitude
of benediction, the hands are maintained until the
operation is ready to begin.

DEATH UNDER THE FINGER-NAIL 339

Then comes the patient ! If his condition will in any
wise permit, he has been given a boiling hot bath and
scrub the night before, and put to bed in a sterilized
nightgown between sterilized sheets. The region
which is to be operated upon has, at the same time,
been scrubbed and rubbed and flushed with hot water,
germicides, alcohol, soap, — in fact, has gone through
the same sacred ceremonial of cleansing through which
the surgeons' hands have passed ; and a large, closely
fitting antiseptic dressing, covering the whole field, has
been applied and tightly bound. He is brought into a
waiting-room and put under ether by an anaesthetist,
through a sterilized mask ; he is then wheeled into the
operating-room, the dressing is removed, a thorough
double scrub is again given, for " good measure," to
the whole area in which the wound is to be made. A
big sheet is thrown over the lower part of his body,
another over the upper part, a third, with an oval open-
ing in the centre of it, thrown over the region to be
operated upon. The instrument nurse takes a boiled
knife out of a sterilized dish of distilled water, hands it
to the surgeon, who takes it in his gloved hand, and the
operation begins.

Now, if you can think of any possible chink through
which a wandering streptococcus can, by any possi-
bility, sneak into that wound, please suggest it, and it
shall be closed immediately !

The intruders against whom all these preparations
are made are two in number: Streptococcus pyogenes
and Staphylococcus pyogenes — cousins, as you see,
by their names. Their last (not family) name really

340 PREVENTABLE DISEASES

means something, and is not half so alarming as it
sounds, as it is Greek for " pus-making." Their
real family name, Coccus, which means a berry, was
suggested, by their rounded shape under the micro-
scope, to some poetically minded microscopist. Unde-
sirable citizens, both of them ! But the older, or Strepto,
cousin is by far the more dangerous character and des-
perate individual, giving rise to and being concerned in
nearly all the civilized and dangerous wound-fevers —
septicaemia, erysipelas, etc. Staphylococcus is a milder
and less harmful individual, seldom going farther than
to produce the milder forms of festering, discharging,
refusing to heal, pustules, etc. He is not to be given a
yard of leeway, however, for if he can get a sufficient
number of dirty wounds to run through, he can work
himself up to a high degree of virulence and poisoning
power. Indeed, this faculty of his may possibly furnish
a clew as to how these pus-makers developed their power
of living in wounds, and almost nowhere else. There
is another cousin also, in the group, called Staphy-
lococcus pyogenes albus, to distinguish him (albus,
" white ") from the other two, who have the tag name
aureus (golden). He is an almost harmless denizen
of the surfaces of our bodies, particularly the mouths
of the sweat-ducts, and the openings of the hair folli-
cles. Under peculiarly favorable circumstances, such
as a very big wound, an aggravated chafe, or the ap-
plication of that champion " bug-breeder," a poul-
tice, he may summon up courage enough to attack
some half-dead skin-cells and make a few drops of
pus on his own account. He is the criminal concerned

DEATH UNDER THE FINGER-NAIL 341

in the so-called stitch-abscesses, or tiny points of pus
which form around the stitches of a big wound and
in some of the smaller pimples which turn to " matter."
It is conceivable that this feeble and harmless white
coccus may at some time have been accelerated under
favorable circumstances' to where he was endowed
with "yellow" powers, and even, upon another turn
of the screw, with strepto-virulence. But this is a
mere academic question. Practically the only thing
needful is to keep all the rascals out of every wound.
Now comes the question, how is this to be done ?
Fortunately it is not necessary to hunt out and destroy
the pus-germs in their breeding-places outside of the
human body. As we have seen, they do not long retain
their vitality out of doors, or as a rule even in the dust
of rooms and dirt of houses, unless the latter have been
recently contaminated with the dressings of, or dis-
charges from, wounds. There are two main things to
be watched: first, the wound itself, and second, any
unwashed or unsterilized part of your own or some
other living body. Dirt of all sorts is a mighty good
thing to keep absolutely out of the wound, but prac-
tically a whole handful of ordinary soil or dust rubbed
into a wound might not, unless it happened to contain
fertilizer of some sort, be half so dangerous as a single
touch with a finger which had been dressing a wound,
picking a scab out of the nose, rubbing an ulcerated
gum, or scratching an itching scalp. If it be a cut on
the finger, or scratch on the hand, for instance, don't
suck it, or lick it, unless you can give an absolutely
clean bill of health to your gums and teeth. If not

342 PREVENTABLE DISEASES

thoroughly brushed three or four times a day, they are
sure to be swarming with germs of twenty or thirty
different species, which not infrequently include one
or both of the pus-germs. Indeed, the real reason why
the bite of certain animals, and above all of a man,
particularly of a " blue-gum nigger," is regarded as so
dangerous is on account of the swarms of germs that
breed in any remnants of food left between the teeth
or in the pockets of ulcerating gums. Many a human
bite is almost as dangerous as a rattlesnake's. The
devoted hero who sucks the poison of the dagger out
of the wound may be conferring a doubtful benefit, if
he happens to be suffering from Rigg's disease.

Don't try to stop the bleeding unless it comes in
spurts or the flow is serious. The loss of a few tea-
spoonfuls, tablespoonfuls, or, for the matter of that,
cupfuls, of blood won't do you any harm, and its free
flow will wash out the cut from the bottom, and carry
out most of the germs that may happen to be present
on the knife or nail. If water and dressings are not
accessible, let the blood cake and dry over the wound
without disturbing it, even though it does look rather
gory.

A slight cut with a clean knife, or other instrument,
into which no dirt has been rubbed, will often require
no other dressing than its own blood-scab. If, however,
as oftener happens, you cannot be sure of the cleanness
of the knife, tool, or nail, hold the wound under running
water from a pump or tap (this is not germ-free, but
practically never contains pus-germs) , until the wound
has been thoroughly washed out, wiping any gravel

DEATH UNDER THE FINGER-NAIL 343

or dirt out of the cut with soft rags which have been
recently washed, or baked in the oven; then dry with
a small piece of linen, or white goods, put on a dressing
of absorbent cotton such as can be purchased for a few
cents an ounce at any drug store. Absorbent or surgi-
cal cotton makes a good dressing, because it both sucks
up any fluids which might leak out of the wound, and
forms a mesh-filter through which no germs can pene-
trate.

It is not advisable to use sticking-plaster for any but
the most trivial wounds, and seldom even for these,
for several reasons. First, because its application usu-
ally involves licking itlo make it stick; second, because
it must cover a sufficient amount of skin on either side
of the wound to give it firm grip, and this area of skin
contains a considerable number of both sweat-ducts
and hair-follicles, which will keep on discharging under
the plaster, producing a moist and unhealthy condition
of the lips of the wound. Moreover, these sweat-ducts
and hair-follicles will, as we have seen, frequently con-
tain white staphylococci, which are at times capable of
setting up a low grade of inflammation in the wound.
A wound always heals better if its surfaces and
coverings can be kept dry. This is why cotton makes
such an ideal dressing, since it permits the free evap-
oration of moisture, a moderate access of air, and yet
keeps out all germs.

If the cut or scratch is of any depth or seriousness
whatever, or the knife, tool, or other instrument be
dirty, or if any considerable amount of street-dust or
garden-soil has got into the wound, then it is, by all

344 PREVENTABLE DISEASES

means, advisable to go to a physician, have the wound
thoroughly cleaned on antiseptic principles, and put up
in antiseptic dressing. A single treatment of this sort,
in a comparatively trifling wound which has become
in any way contaminated, may save weeks of suffer-
ing and disability, and often danger of life, and will in
eight cases out of ten shorten the time of healing from
forty to sixty per cent. The rapidity with which a
wound in a reasonably healthy individual, cleaned
and dressed on modern surgical principles, will heal,
is almost incredible, until it has actually been seen.

The principal danger of garden-soil or street-dust
in a wound is not so much from pus-germs, though
these may be present, as from another " bug " — the
tetanus or lockjaw bacillus. This deadly organism
lives in the alimentary canal of the horse, and hence
is to be found in any dirt or soil which contains horse
manure. It is, fortunately, not very common, or
widely spread, but enough so to make it the part of
prudence to have thoroughly asepticized and dressed
any wound into which considerable amounts of garden-
soil, or street-dust, have been rubbed. The reason
why wounds of the feet and hands have had such
a bad reputation, both for festering and giving rise
to lockjaw, is that it is precisely in these situations
that they are most likely to get garden-soil, or stable
manure, into them. The classic rusty nail does not de-
serve the bad reputation as a wound-maker which it
enjoys, its bad odor being chiefly due to the fact al-
ready referred to, that injuries inflicted by it are most
apt to be in the palm of the hand, or in the sole of the

DEATH UNDER THE FINGER-NAIL 345

foot, and hence peculiarly liable to contamination by
the tetanus and other soil bacilli.

For some reason or other which we don't as yet thor-
oughly understand, burns from a toy pistol in particular,
and Fourth of July fireworks in general, seem to be
peculiarly liable to be followed by tetanus. The ful-
minate used in the cap of a toy pistol, and the paper
and explosives of several of the brands of firecrackers,
have been thoroughly examined bacteriologically, but
without finding any tetanus germs in them. So many
cases of lockjaw used to follow the Fourth of July
celebrations a few years ago, that Boards of Health be-
came alarmed, and not only forbade outright the sale
of deadly toy pistols, but provided supplies of the teta-
nus antitoxin at various depots throughout the cities,
so that all patriotic wounds of this description could
have it dropped into them when they were dressed.
Since then, the lockjaw penalty which we pay for
our highly intelligent method of celebrating the Fourth,
has diminished considerably. It is probable that the
mortality was chiefly due to infection of the ugly, slow-
healing, dirty little wounds with city-dust, a large per-
centage of which, of course, is dried horse manure.
What with the tetanus bacillus and the swarms of flies
which breed chiefly in stable manure, and carry
summer diseases, typhoid, diphtheria, and tuberculo-
sis in every direction, it will not be long before the
keeping of horses within city limits will be as strictly
forbidden as pigpens now are.

So definite is the connection between the tetanus
bacilli and the soil, that tetanus fields or lockjaw gar-

346 PREVENTABLE DISEASES

dens are now recognized and listed by the health
authorities, on account of their having given rise to
several successive cases of the disease. Workers in
such fields or gardens, who scratch or cut themselves,
are warned to report themselves promptly for treat-
ment with the tetanus antitoxin.

Apart from the tetanus germ, however, the problem
of the treatment of wounds — while there should be
perfect cleanliness, the spotlessness of the model house-
keeper multiplied fivefold — is yet not so much a
matter of keeping dirt in general out of the wound, as
of keeping out that particular form of dirt which con-
sists of, or contains, discharges from some previous
wound, sore, ulcer, or boil!

While both these pus-organisms can breed and
flourish freely only in wounds or sores, this is but their
starting-point where they gather strength to invade
the entire organism. We used to make a distinction
between those cases in which their toxins or poison-
products got into the blood, with the production of
fever, headache, backache, delirium, sweats, etc.,
which we term septicaemia, and other cases in which
the cocci themselves were carried into the blood and
swept all over the body by forming fresh foci, or breed-
ing-places, which resulted in abscesses all over the
body, which we call pyaemia. But now we know that
there is no hard and fast line to be drawn, and that
the germs get into the blood much more easily than
we supposed ; and the degree and dangerousness of the
fever which they set up depend, first, upon their viru-
lence, or poisonousness, and, second, upon the resisting

DEATH UNDER THE FINGER-NAIL 347

power of the patient at the time. Anything which lowers
the general health and strength and weakens the re-
sisting power of the body will make it much easier for
pus-germs to get an entrance into it, and overwhelm
it; so that, after prolonged famines for instance, or
among the population of besieged cities, or in armies
or exploring expeditions which have been deprived of
food and exposed to great hardship, the merest scratch
will fester and inflame, and give rise to a serious and
even fatal attack of blood-poisoning, erysipelas, hos-
pital gangrene, etc. Famines and sieges in fact are not
infrequently followed by positive epidemics of blood-
poisoning, often in exceedingly severe and fatal forms.

It was long ago noted by the chroniclers that the
death-rate from wound-fever among the soldiers of a
defeated army was apt to be much greater than among
those of the victorious one, and this was quoted as one
of the stock evidences of the influence of mind over
body. But we now know that armies are not beaten
without some physical cause, that the defeated soldiers
are apt to be in poorer physical condition to begin
with ; that they have often been cut off from their base
of supplies, have made desperate forced marches
without food or shelter in the course of their retreat ;
and, until within comparatively recent years, were
never half so well treated or well fed as their cap-
tors.

As the invading germs pass into the body, they travel
most commonly through the lymph-channels and skin ;
are arrested and threatened with destruction by the so-
called lymphatic glands, or lymph-nodes. This is why,

348 PREVENTABLE DISEASES

if you have a festering wound or boil on your hand or
wrist, the " kernels " or lymph-nodes up in your
armpit will swell and become painful. If the lymph-
nodes can conquer the germs and eat them up, the
swelling goes down and the pain disappears. But if
the germs, on the other hand, succeed in poisoning and
killing the cells of the body, these latter melt down and
turn to pus, and we get what we call a " secondary
abscess."

The next commonest point of attack of these pus-
germs, if they once get into the body, and by far the
most dangerous, is the heart, as in rheumatism and other
fevers. Some will also attack the kidneys, giving rise
to albumin in the urine, while others attack the mem-
branes of the joints (synovia) and cause suppuration
of one or more joints in the body, which is very apt to
be followed by very serious stiffening or crippling. So
that, common, and, in many instances, comparatively
mild as they are, the pus-germs in the aggregate are
responsible for a very large amount of damage to the
human body.

This is the way the streptococcus and staphylococcus
behave in an open wound, or sore; but they have two
other methods of operating which are somewhat special
and peculiar. One of these is where the germ digs and
burrows, as it were, underground, in a limited space,
resulting in that charming product known as a boil, or a
carbuncle. The other, where it spreads rapidly over
the surface just under the skin, after the fashion of
the prairie fire, producing erysipelas. In the first of
these he behaves like the famous burrowing owl of our

DEATH UNDER THE FINGER-NAIL 349

Western plains, who forms, with the prairie-dog, the so-
called "happy family." He never makes his own bur-
row, he simply uses one which is already provided for
him by nature, and that is the little close-fitting pouch
surrounding the root of a hair. Whether the criminal
is a harmless native white coccus which has suddenly
developed anti-social tendencies, or a Mongolian im-
migrant who has been accidentally introduced, is still
an open question. The probabilities are that it is more
frequently the latter, as, while boils are absolutely no
respecters, either of persons or places, and may rear
their horrid heads in every possible region of the hu-
man form divine, yef they display a very decided ten-
dency to appear most frequently in regions like the back
of the neck, the wrist, the hips, and the nose. One
thing that these areas have in common is that they are
liable to a considerable amount of chafing and scratch-
ing as by collars and stocks on the neck, and cuffs on
the wrists, or of friction from belts, or pressure or chaf-
ing from chairs or saddles. When the tissues have
been bruised or chafed after such fashion, especially
if the surface of the skin has been at the same time
broken, and any pus-organism is either present in the
hair-follicle, like the white coccus, or rubbed into it
by a finger or finger-nail which has just been sucked
in the mouth, used to pick the nose, or possibly en-
gaged in dressing some wound, or cutting meat, or
handling fertilizer, then all the materials for an ex-
plosion are at hand.

CHAPTER XVI

CANCER, OR TREASON IN THE BODY-STATE

THE imagination of the race has ever endowed
Cancer with a peculiar individuality of its own.
Although it has vaguely personified in darkest ages
other diseases, like the Plague, the Pestilence, and
Maya (the Smallpox), these have rapidly faded away
in even the earliest light of civilization, and have never
approached in concreteness and definiteness the ma-
levolent personality of Cancer. Its sudden appearance,
the utter absence of any discoverable cause, the twinges
of agonizing pain that shoot out from it in all directions,
its stone-like hardness in the soft, elastic flesh of the
body, the ruthless way in which it eats into and destroys
every organ and tissue that come in its way, make this
impression, not merely of personality, but of positive
malevolence, almost unescapable.

Its very name is instinct and bristling with this idea :
Krebs, in German, Cancer, in Latin, French, and Eng-
lish, Carcinoma, in Greek, all alike mean " Crab," a
ghastly, flesh-eating parasite, gnawing its way into the
body. The simile is sufficiently obvious. The hard
mass is the body of the beast; the pain of the growth
is due to his bite ; the hard ridges of scar tissue which
radiate in all directions into the surrounding skin are
his claws.

The singular thing is that, while brushing aside, of

CANCER 351

course, all these grotesque similes, the most advanced
researches of science are developing more and more
clearly the conception of the independent individuality
— as they term it, the autonomy — of cancer.

More and more decidedly are they drifting toward the
unwelcome conclusion that in cancer we have to deal
with a process of revolt of a part of the body against
the remainder, " a rebellion of the cells," as an eminent
surgeon-philosopher terms it. Unwelcome, because a
man's worst foes are " they of his own household."
Successful and even invigorating warfare can be waged
against enemies without, but a contest with traitors
within dulls the spear and paralyzes the arm. Against
the frankly foreign epidemic enemies of the race a
sturdy and, of late years, a highly successful battle
has been fought. We have banished the plague, drawn
the teeth of smallpox, riddled the armor of diphtheria,
and robbed consumption of half its terrors. In spite
of the ravings and gallery-play of the Lombroso school
anent " degeneracy," our bills of mortality show a
marked diminution in the fatality of almost every
important disease of external origin which afflicts hu-
manity.

The world-riddle of pathology the past twenty years
has been : Is cancer due to the invasion of a parasite, a
veritable microscopic crab, or is it due to alterations in
the communal relations, or, to speak metaphorically,
the allegiance of the cells ? Disappointing as it may be,
the balance of proof and the opinion of the ablest
and broadest-minded experts are against the parasitic
theory, so far, and becoming more decidedly so. In

352 PREVENTABLE DISEASES

other words, cancer appears to be an evil which the
body breeds within itself.

There is absolutely no adequate ground for the tone
of lamentation and the Cassandra-like prophecy which
pervade all popular, and a considerable part of medi-
cal, discussion of the race aspects of the cancer prob-
lem. The reasoning of most of these Jeremiahs is
something on this wise : That, inasmuch as the deaths
from cancer have apparently nearly trebled in propor-
tion to the population within the last thirty years, it
only needs a piece of paper and a pencil to be able to
figure out with absolute certainty that in a certain
number of decades, at this geometric ratio, there will
be more deaths from cancer than there are human be-
ings living.

There could be no more striking illustration, both of
the dangerousness of "a little knowledge" and of the
absurdity of applying rigid logic to premises which con-
tain a large percentage of error. Too blind a confidence
in the inerrancy of logic is almost as dangerous as super-
stition. Space will not permit us to enter into details,
but suffice it to say : —

First, that expert statisticians are in grave doubt
whether this increase is real or only apparent, due to
more accurate diagnosis and more complete recording
of all cases occurring. Certainly a large proportion of
it is due to the gross imperfection of our records thirty
years ago.

Second, that the apparent increase is little greater
than that of deaths due to other diseases of later life,
such as nervous, kidney, and heart diseases. Our heavi-

CANCER 353

est saving of life so far is in the first five-year period,
and more children are surviving to reach the cancer
and Bright 's disease age.

Third, that a disease, eighty per cent of whose death-
rate occurs after forty-five years of age, is scarcely
likely to threaten the continued existence of the race.

The nature of the process is a revolt of a group of
cells. The cause of it is legion, for it embraces any in-
fluence which may detach the cell from its normal sur-
roundings, — " isolate it," as one pathologist expresses
it. The cure is early and complete amputation of not
only the rebellious cells, but of the entire organ or re-
gion in which they occur.

A cancer is a biologic anomaly. Everywhere else in
the cell-state we find each organ, each part, strictly sub-
ordinated, both in form and function, to the interests
of the whole.

Here this relation is utterly disregarded. In the
body-republic, where we have come to regard harmony
and loyalty as the invariable rule, we find ourselves
suddenly confronted by anarchy and revolt.

The process begins in one great class of cells, the
epithelium of the secreting glands. This is a group of
cell-citizens of the highest rank, descended originally
from the great primitive skin-sheet, which have formed
themselves into chemical laboratories, ferment-facto-
ries for the production of the various secretions required
by the body, from the simplest watery mucus, as in the
mouth, or the mere lubricant, as in the fat-glands of the
hair-follicles, to the most complex gastric or pancreatic
juice. They form one of the most active and import-

354 PREVENTABLE DISEASES

ant groups in the body, and their revolt is dangerous
in proportion.

The movement of the process is usually somewhat
upon this order: After forty, fifty, or even sixty years
of loyal service, the cells lining one of the tubules of a
gland — for instance, of the lip, or tongue, or stomach
- begin to grow and increase in number. Soon they
block up the gland-tube, then begin to push out in the
form of finger- or root-like columns of cells into the
surrounding tissues.

These columns appear to have the curious power of
either turning their natural digestive ferments against
the surrounding tissues, or secreting new ferments for
the purpose, closely resembling pepsin, and thus literally
eating their way into them. So rapidly do these cells
continue to breed and grow and spread resistlessly in
every direction, that soon the entire gland, and next
the neighboring tissues, become packed and swollen,
so that a hard lump is formed, the pressure upon the
nerve-trunks gives rise to shooting pains, and the first
act of the drama is complete.

But these new columns and masses, like most other
results of such rapid cell-breeding in the body, are liter-
ally a mushroom growth. Scarcely are they formed
before they begin to break down, with various results.
If they lie near a surface, either external or internal,
they crumble under the slightest pressure or irritation,
and an ulcer is formed, which may either spread slowly
over the surface, from the size of a shilling to that of a
dinner-plate, or deepen so rapidly as to destroy the
entire organ, or perforate a blood-vessel and cause

CANCER 355

death by hemorrhage. The cancer is breaking down
in its centre, while it continues to grow and spread at
its edge. Truly a " magnificent scheme of decay."

Then comes the last and strangest act of this weird
tragedy. In the course of the resistless onward march
of these rebel cell-columns some of their skirmishers
push through the wall of a lymph-channel, or even,
by some rare chance, a vein, and are swept away by the
stream. Surely now the regular leucocyte cavalry have
them at their mercy, and can cut them down at leisure.
We little realize the fiendish resourcefulness of the
cancer-cell. One such adrift in the body is like a ferret
in a rabbit warren ; rfo other cell can face it for an instant.
It simply floats unmolested along the lymph-channels
until its progress is arrested in some way, when it
promptly settles down wherever it may happen to have
landed, begins to multiply and push out columns in every
direction, into and at the expense of the surrounding
tissues, and behold, a new cancer, or " secondary
nodule," is born (metastasis).

In fact, it is a genuine "animal spore," or seed-cell,
capable of taking root and reproducing its kind in any
favorable soil; and, unfortunately, almost every inch
of a cancer patient's body seems to be such. It is merely
a question of where the spore-cells happen to drift and
lodge. The lymph-nodes or " settling basins" of the
drainage area of the primary cancer are the first to be-
come infected, probably in an attempt to check the in-
vaders ; but the spores soon force their way past them
toward the central citadels of the body, and, one after
another, the great, vital organs — the liver, the lungs,

356 PREVENTABLE DISEASES

the spleen, the brain — are riddled by the deadly
columns and choked by decaying masses of new cells,
until the functions of one of them are so seriously in-
terfered with that death results.

Obviously, this is a totally different process, not
merely in degree, but in kind, from anything that takes
place as a result of the invasion of the body by an in-
fectious germ or parasite of any sort. There is a certain
delusive similarity between the cancer process and an
infection. But the more closely and carefully this simi-
larity is examined the more superficial and unreal does
it become. The invading germ may multiply chiefly
at one point or focus, like cancer, and from this spread
throughout the body and form new foci, and may even
produce swarms of masses of cells resembling tumors,
as, for instance, in tuberculosis and syphilis. But here
the analogy ends.

The great fundamental difference between cancer
and any infection lies in the fact that, in an infection,
the inflammations and poisonings and local swellings
are due solely and invariably to the presence and
multiplication of the invading germs, which may be
recovered in millions from every organ and region
affected, while swellings or new masses produced are
merely the outpouring of the body-cells in an attempt
to attack and overwhelm these invaders. In cancer,
on the contrary, the destroying organism is a group of
perverted body-cells. The invasion of other parts of
the body is carried out by transference of their bastard
and abortive offspring. Most significant of all, the new
growths and swellings that are formed in other parts

CANCER 357

of the body are composed, not of the outpourings of the
local tissues, but of the descendants of tliese pirate cells.
This is one of the most singular and incredible things
about the cancer process : that a cancer starting, say,
in the pancreas, and spreading to the brain, will there
pile up a mass — not of brain-cells, or even of connec-
tive tissue-cells — but of gland-cells, resembling crudely
the organ in which it was born. So far will this resem-
blance go that a secondary cancer of the pancreas found
in the lung will yield on analysis large amounts of
trypsin, the digestive ferment of the pancreas. Similarly
a cancer of the rectum, invading the liver, will there
pile up in the midst of the liver-tissue abortive attempts
at building up glands of intestinal mucous membrane.

This fundamental and vital difference between the
two processes is further illustrated by this fact : While
an ordinary infection may be transferred from one in-
dividual to another, not merely of the same species, but
of half a dozen different species, with perfect certainty,
and for any number of successive generations, no case
of cancer has ever yet been known to be transferred
from one human being to another. In other words,
the cancer-cell appears utterly unable to live in any
other body except the one in which it originated.

So confident have surgeons and pathologists become
of this that a score of instances are on record where
physicians and pathologists, among them the famous
surgeon-pathologist, Senn, of Chicago, only a few years
ago, have voluntarily ingrafted portions of cancerous
tissue from patients into their own arms, with absolutely
no resulting growth. In fact, the cancer-cell behaves

358 PREVENTABLE DISEASES

like every other cell of the normal body, in that, though
portions of it can be grafted into appropriate places in
the bodies of other human beings and live for a period
of days, or even months, they ultimately are completely
absorbed and disappear. The only apparent exception
is the epithelium of the skin, which can be used in
grafting or skinning over a wide raw surface in another
individual. However, even here the probability appears
to be that the taking root of the foreign cells is only
temporary, and makes a preliminary covering or protec-
tion for the surface until the patient's own skin-cells
can multiply fast and far enough to take its place.

A similarly reassuring result has been obtained in
animals. Not a single authenticated case is on record
of the transference of a human cancer to one of the lower
animals; and of all the thousands and thousands of
experiments that have been made in attempting to
transfer cancers from one animal to another, only one
variety of tumor with the microscopic appearance of
cancer — the so-called Jensen's tumor of mice — has
yet been found which can be transferred from one ani-
mal to another.

So we may absolutely disabuse our minds of the fear
which some of our enthusiastic believers in the para-
sitic theory of cancer have done much to foster, that
there is any danger of cancer " spreading," like an in-
fectious disease. Disastrous and gruesome as are the
conditions produced by this disease, they are absolutely
free from danger to those living with or caring for the
unfortunate victim. In the hundreds of thousands of
cases of cancers which have been treated, in private

CANCER 359

practice, in general hospitals, and in hospitals devoted
exclusively to their care, not a single case is on record
of the transference of the disease to a husband, wife,
or child, nurse or medical attendant. So that the cancer
problem, like the Kingdom of Heaven, is within us.

This conclusion is further supported by the disap-
pointing result of the magnificent crusade of research
for the discovery of the cancer " parasite," whether
vegetable or animal, which has been pursued with a
splendid enthusiasm, industry, and ability by the best
blood and brains of the pathological world for twenty
years past. I say disappointing, because a positive
result — the discovery and identification of a parasite
which causes cancer — would be one of the greatest
boons that could be granted to humanity ; not so much
on account of the actual loss of life produced by the
disease as for the agonies of apprehension engendered
by the fact of the absolute remorselessness and blind-
ness with which it may strike, and our comparative
powerlessness to cure. So far the results have been dis-
tressingly uniform and hopelessly negative.

Scores, yes, hundreds, of different organisms have
been discovered in and about cancerous growths, and
announced by the proud discoverer as the cause of
cancer. Not one of these, however, has stood the test
of being able to produce a similiar growth by inocula-
tion into another body ; and all which have been deemed
worthy of a test-research by other investigators besides
the paternal one have been found to be mere accidental
contaminations, and present in a score of other dis-
eases, or even in normal conditions. Many of them have

360 PREVENTABLE DISEASES

been shown to be abnormal products of the cells of
the body in the course of the cancer process, and some
even such ludicrous misfits as impurities in the chemical
reagents used, scrapings from the corks of bottles,
dust from the air, or even air-bubbles. These "dis-
coveries" have ranged the whole realm of unicellular
life, — bacilli, bacteria, spirilla, yeasts, moulds, pro-
tozoa, — yet the overwhelming judgment of broad-
minded and reputable experts the world over is the
Scotch verdict of "not proven"; and we are more and
more coming to turn our attention to the other aspect of
the problem, the factors which cause or condition
this isolation and assumption of autonomy on the part
of the cells.

This is not by any means to say that there is no
causative organism, and that this will not some day be
discovered. Human knowledge is a blind and short-
sighted thing at best, and it may be that some invading
cell, which, from its' very similarity to the body-cells,
has escaped our search, will one day be discovered.
Nor will the investigators diminish one whit of their
vigor and enthusiasm on account of their failure thus
far.

The most strikingly suggestive proof of the native-
born character of cancer comes from two of its biologic
characters. The first is that its habit of beginning
with a mass formation, rapidly deploying into columns
and driving its way into the tissues in a ghastly flying
wedge, is simply a perfect imitation and repetition of
the method by which glands are formed during the
development of the body. The flat, or epithelial, cells

CANCER 361

of the lining of the stomach, for instance, begin to pile
up in a little swarm, or mass, elongate into a column,
push their way down into the deeper tissue, and then
hollow out in their interior to form a tubular gland.
The only thing that cancer lacks is the last step of form-
ing a tube, and thereby becoming a servant of the body
instead of a parasite upon it.

Nor is this process confined to our embryonic or
prenatal existence. Take any gland which has cause
to increase in size during adult life, as, for instance,
the mammary gland, in preparation for lactation, and
you will find massing columns and nests of cells push-
ing out into the surrounding tissue in all directions,
in a way that is absolutely undistinguishable in its ear-
lier stages from the formation of cancer. It is a fact
of gruesome significance that the two organs — the
mammary gland and the uterus — in which this pro-
cess habitually takes place in adult life are the two
most fatally liable to the attack of cancer.

Another biologic character is even more striking and
significant. A couple of years ago it was discovered by
Murray and Bashford, of the English Imperial Cancer
Research Commission, that the cells of cancer, in their
swift and irregular reproduction, showed an unexpected
peculiarity. In the simplest form of reproduction, one
cell cutting itself in two to make two new ones, known
as mitosis, the change begins in the nucleus, or kernel.
This kernel splits itself up into a series of threads or
loops, known as the chromosomes, half of which go
into each of the daughter cells. When, however, sex
is born and a male germ-cell unites with a female germ-

362 PREVENTABLE DISEASES

cell to form a new organism, each cell proceeds, as the
first step in the process, to get rid of half of these
chromosomes, so that the new organism has precisely
the normal number of chromosomes, half of which are
derived from the father and the other half from the
mother germ-cell. This, by the way, is the mechanical
basis of heredity.

It has been long known that the mitotic processes
of cancer and the forming and dividing of the chromo-
somes were riotous and irregular, like the rest of its
growth. But it was reserved for these investigators to
discover the extraordinary fact that the majority of
dividing and multiplying cancer-cells had, instead of
the normal number of chromosomes, exactly half the
quota. In other words, they had resumed the powers
of the germ, or sexual, cells from which the entire body
was originally built up, and were, like them, capable
of an indefinite amount of multiplication and repro-
duction. How extraordinary and limitless this power
is may be seen from the fact that a little group of cancer-
cells grafted into a mouse to produce a Jensen tumor,
from which a' graft is again taken and transplanted
into another mouse, and so on, is capable, in a com-
paratively few generations, of producing cancerous
masses a thousand times the weight of the original
mouse in which the tumor started !

In short, cancer-cells are obviously a small, isolated
group of the body-cells, which in a ghastly fashion have
found the fountain of perpetual youth, and can ride
through and over the law-abiding citizens of the body-
state with the primitive vigor of the dawn of life.

CANCER 363

This brings us to the most practical and important
questions of the problem: What are the influences
which condition this isolation and outlawry of the cells ?
What can we do to prevent or suppress the rebellion ?
To the first of these science can only return a tentative
and approximate answer. The subject is beset with
difficulties, chief among which is the fact that we are
unable to produce the disease with certainty in ani-
mals, with the single exception of the Jensen's tumors
in mice referred to, nor is it transferred from one
human being to another, so that we can make even
an approximate gue^s at the precise time at, or condi-
tions under, which the process began.

Many theories have been advanced, but most investi-
gators who have studied the problem in a broad-minded
spirit are coming gradually to agree to this extent : —

First of all, that one of the most powerful influences
conditioning this isolation and revolt of the cells is age,
both of the individual and of the organ concerned.
Not only does far the heaviest cancer mortality fall
between the ages of forty-five and sixty, but the organs
most frequently and severely attacked are those which
between these years are beginning to lose their function
and waste away. First and most striking, the mammary
gland and the uterus in women, and the shriveling lips
and tongue of elderly men. To put it metaphorically,
the mammary gland and the uterus, after the change of
life, the lip, after the decay of the teeth, have done their
work, outlived their usefulness, and are being placed
upon a starvation pension by a grateful country.
Nineteen out of twenty accept the situation without

364 PREVENTABLE DISEASES

protest and sink slowly to a mere vegetative state of
existence, but, in the twentieth, some little knot of cells
rebel, revert to an ancestral power of breeding rapidly
to escape extinction, begin to make ravages, and can-
cer is born.

The age-preferences are well marked. Cancer is
emphatically a disease of senility, of age; but, as
Roger Williams has pointed out in his admirable
monograph, not of " completed " senility.

To express it in percentages, barely twenty per cent
of the cases occur before forty years of age, sixty per
cent between forty and sixty, and twenty per cent
between sixty and eighty. Thus the early period of
decline, the transition stage between full functional
vigor and declared atrophy (wasting) of the glands,
is clearly the period of greatest danger; precisely the
period in which the gland-cells, though losing their
function, — and income, — have still the strength to in-
augurate a rebellion, and a sufficient supply of the
sinews of war, either in their own possession or within
easy striking distance in the tissues about them, to
make it successful. Not less than sixty-five to seventy-
five per cent of all cancers in women occur in atrophy-
ing organs, the uterus and mammary glands.

A rather alluring suggestion was made by Cohnheim,
years ago, that cancers might be due to the sudden
resumption of growth on the part of islands or rests of
embryonic tissue, left scattered about in various parts
of the body. But these are now believed to play but a
small part, if indeed any, in the production of true
cancer.

CANCER 365

Finally, what can be done to prevent or cure this
grotesque yet deadly process ? So far as it is conditioned
by age, it is, of course, obvious that little can be done,
for not even the most radical vivisector would propose
preventing in any way as large a proportion as possible
of the human race from reaching fifty or sixty, or
even seventy years, to avoid the barely six per cent
liability to cancer after forty-five.

As regards the influence of chronic inflammations
and irritation, much can be done, and here is our most
hopeful field for prevention. Warts and birthmarks
that are in any way^ subject to pressure or friction
from clothing or movements should be promptly re-
moved, as both show a distinctly greater tendency than
normal tissue to develop into cancer. Cracks, fissures,
chafes, and ulcers of all sorts, especially about the lips,
tongue, mammary gland, uterus, and rectum, should
be early and aseptically dealt with. Jagged remnants
of teeth should be removed, all suppurative processes
of the gums antiseptically treated, and the whole mouth-
parts kept in a thoroughly aseptic condition.

Thorough and conscientious attention to this sort
of surgical toilet work is valuable, not only for its
preventive effect, — which is considerable, — but also
because it will insure the bringing under competent
observation at the earliest possible moment the be-
ginnings of true cancer.

For the disease itself, after it has once started, there
is, like treason in the body-politic, but one remedy —
capital punishment. Parleying with the rebels is worse
than useless. Pastes, caustics, X-rays, trypsin, ra-

366 PREVENTABLE DISEASES

dium, — all are fatally defective, because they suppress
a symptom only and leave the cause untouched. Only
in one form of surface-cancer, the so-called flat-celled
or rodent ulcer, which has little or no tendency to form
spore-cells and attack the deeper organs, are they
effective.

Nothing is easier and nothing more idle than to de-
stroy and break down cells which have actually become
cancerous; but so long as there remains in the body a
single nest, or even cell, of the organ in which the re-
volt started, so long the life of the patient is in danger.

Absolutely the only remedy which is of the slightest
value is complete removal with the knife. The one su-
periority of the knife, shudder as we may at the name
of it, over every other means of removal lies solely in
this fact, that with it can be removed not merely the
actual cancer, but the entire gland or group of sur-
rounding cells in which this malignant, parricidal
change has begun to occur.

The modern radical operations for cancer take not
merely the tumor, but the entire diseased breast, for
instance, and all the lymph-glands into which it drains,
clear up into the armpit, with the muscles beneath it
down to the ribs. Where this is done early enough, the
disease does not recur. Such radical and complete am-
putation of an organ or region as this is possible in
from two-thirds to three-fourths of all cases if seen
reasonably early.

With watchfulness and courage, our attitude toward
the cancer problem is one of hopeful confidence.

CHAPTER XVII

HEADACHE: THE MOST USEFUL PAIN IN THE WORLD

REATNESS always has its penalties. Other ills
besides death love a shining mark. Pain is one
of them, and headache its best exemplar. If there be
one thing about our bodies of which we are peculiarly
and inordinately proud it is that expanded brain-bulb
which we call the head. Yet it aches oftener than all the
rest of us put together. Headache is the commonest of
all pains, which fact gives the slight consolation that
everybody can sympathize with you when you have it.
One touch of headache makes the whole world kin, and
the man or woman who has never had it would be
looked upon as a creature abnormal and "a thing
apart." It has even become incorporated into our
social fabric as one of the sacred institutions of the
game of polite society. How could we possibly protect
ourselves against our instructors in youth and our
would-be friends in later life if there were no such
words as " a severe headache" ?

What is a headache, and why does it ache the head ?
This is a wide and hotly disputed problem. But one
fact, which is obvious at the first intelligent glance,
becomes clearer and more important with deeper study,
and that is that it is not tJw fault of the head. When
the head aches, it is, nine times out of ten, simply doing
a combination of scapegoat and fire-alarm duty for the

368 PREVENTABLE DISEASES

rest of the body. Just as the brain is the servant of the
body, rather than its master, so the devoted head
meekly offers itself as a sort of vicarious atonement
for the sins of the entire body. It is the eloquent spokes-
man of such " mute, inglorious Miltons " as the stomach,
the liver, the muscles, and the heart. The humblest
and least distinguished of all the organs of the body
can order the lordly head to ache for it, and the head
has no alternative but to obey.

To discuss the cause of headaches is like discussing
the cause of the human species. It is one of the com-
monest facts of every-day observation, and can be
demonstrated almost at will, that any one of a hundred
different causes, — a stuffy room, a broken night's sleep,
a troublesome letter, a few extra hours of work, eating
something that disagrees, a cold, a glare of light in the
eyes, — any and all of these may bring on a headache.
The problem of avoiding headaches is the problem of
the whole conduct of life.

Two or three broad generalizations, however, can
be made from the confused and enormous mass of
data at our disposal, which are of both philosophic
interest and practical value. One of these is that,
while headache is felt in the head, and particularly
in those regions that lie over the brain, the brain has
comparatively little to do with the pain. Headache is
neither a mark of intellectuality, nor, with rare excep-
tions, a sign of cerebral disturbance. Indeed, it is far
more a matter of the digestion, the muscles, and the
ductless glands, than it is of the brain, or even of the
nervous system. It is, therefore, idle to endeavor

HEADACHE 369

either to treat or try to prevent it by measures directed
to the head, the brain, or even the nervous system as
such.

Secondly, it is coming to be more and more clearly
recognized that, while its causes are legion, a very large
percentage of these practically and eventually operate
by producing a toxic, or poisoned, condition of the blood,
which, circulating through certain delicate and sensi-
tive nerve-strands in the head and face, give rise to the
sensation of pain.

Thirdly, the tissues which give out this pain-cry
under the torture of the toxins in the blood are, in
a large majority of cases, neither the brain, nor the
nerves of the eye, nor other special senses, but the
nerves of common sensation which supply the face,
the scalp, and the structures of the head generally,
most of them derived from one great pair of nerve-
trunks, the so-called Trigeminus, or fifth pair of
cranial nerves. Strange as it may seem, the brain sub-
stance is comparatively insensitive to pain, and the
acutest pain of an operation upon it, such as for the
removal of a tumor, is over when the skin and scalp
have been cut through. These poisons, of course,
go all over the body, wherever the circulation goes,
but they produce their promptest and loudest pain
outcry, so to speak, in the region where the nerves are
most exquisitely sensitive. When your head aches,
nine times out of ten your whole body is suffering,
but other regions of it are not able to express them-
selves so promptly and so clearly.

These newer and clearer views of the nature of

370 PREVENTABLE DISEASES

headache dispose at once of some of the most time-
honored controversies in regard to its nature. In my
student-days one of the most hotly debated problems
in medicine was as to whether headaches were due to
lack of blood (anaemia) or excess of blood (hyper-
semia) in the brain. Few things could have been more
natural for both the sufferer in, and the observer of, a
case of throbbing, bursting headache, where every
pulse-beat is registered as a thrill of agony, than to
draw the conclusion that the pain was due to a huge
engorgement and swelling of the brain with blood,
resulting in agonizing pressure against its rigid, bony
skull-walls.

One of the most naive and vivid illustrations of this
conception of headache is the remedy adopted for
generations past, in this all too familiar and distressing
condition, by the Irish peasantry. It consists of a band
or strip of tough cloth, or better, of twisted or plaited
straw, which is tied around the head and then tightened
vigorously by means of a stick inserted tourniquet
fashion. This is believed to prevent the head, which is
aching "fit to split," from actually bursting open, and
is considered a cure of wondrous merit through many
a countryside. Ludicrous as is the reason which is
gravely assigned for its use, it does, in some cases,
greatly relieve the pain, a fact which we were entirely
at a loss to account for until our later knowledge showed
us that the pain, instead of being inside the skull, was
outside of it in the sensitive nerves supplying the scalp.
By steady pressure of this sort upon the trunks of these
nerves, pressing them against the bone, they can be

HEADACHE 371

gradually numbed into a condition of anaesthesia,
when naturally the pain would diminish.

In politer circles a similar misapprehension has also
given rise to a favorite form of treatment. That is the
application of cold in the form of the classic wet cloth
sprinkled with eau de Cologne. The mere mention of
headache calls up in the minds of most of us memories
of a darkened room, a pale face on the pillow with a
ghastly bandage over the eyes, and a pervading smell
of eau de Cologne. It was a perfectly natural conclusion
that, because the head throbbed and felt hot and burst-
ing, there must be some inflammation, or at least con-
gestion, present, and that the application of cold would
relieve this. The results seemed to justify this belief,
for in many cases the sense of coolness to the aching
head gives great relief ; but this is apt to be only tem-
porary, and in really severe cases makes the situation
worse by adding another depressing influence — cold
— to the toxin-burdens that are weighing upon the
tortured nerves. The chief virtue in these cold cloths
and handkerchiefs soaked in cologne was that you
were compelled to lie down and keep perfectly still in
order to keep them on, while at the same time they
mechanically blindfolded you. Few better devices for
automatically insuring that absolute rest, which is the
best and only rational cure for a headache, have ever
been invented.

We were not long in discovering that headaches,
both of the mildest and the severest types, might be ac-
companied either by a rush of blood to the head,
with flushing of the skin, reddening of the eyes, and a

372 PREVENTABLE DISEASES

bursting sense of oppression in the head, or, on the other
hand, by an absolute draining of the whole floating
surplus of the blood into the so-called " abdominal
pool," the huge network of vessels supplying the di-
gestive organs, which, when distended, will contain
nearly two-thirds of the entire blood of the body,
leaving the face blanched, the eyes white and staring,
and the brain so nearly emptied of blood as to cause
loss of consciousness or swooning. Other headaches,
again, will be accompanied by a fresh, natural color
and a perfectly normal and healthy distribution of
the blood-supply. In short, the amount of blood in
the head, whether plus or minus, has practically
nothing to do with the pain, but depends solely upon
the effect of the poisons producing it upon the heart
and great blood-vessels.

A good illustration of the full-blooded type of head-
ache is that which so very frequently, indeed almost
invariably, occurs in the early stage of a fever or other
acute infection, such as typhoid, pneumonia, or blood-
poisoning, Here the face is red, the eyes are bloodshot
and abnormally bright, the pulse is rapid and full, the
headache so severe as to become the first disabling
symptom in the disease, — all because this is the effect
of the poison (toxin) of the disease upon the heart, the
temperature, and the surface blood-vessels. Fortu-
nately for the sufferer, this head -pain, like most others
in the course of severe infections, is only preliminary,
for as soon as the tissues of the body have become
thoroughly saturated with the toxins, the nerves be-
come dulled and semi-narcotized, so that they no

HEADACHE 373

longer respond with the pain-cry. As the patient settles
down into the depression and dullness of the regular
course of the fever, the headache usually subsides into
little more than a sense of heaviness, or oppression and
vague discomfort.

Moral : It is a sign of health to be able to feel a head-
ache, an indication that your body is still fighting
vigorously against the enemy, whether traitor within
or foe without.

On the other hand, many of our most agonizing,
and particularly our most persistent and obstinate
headaches, occur in individuals who are markedly
anaemic, with a low, weak pulse, poor circulation,
blanched lips, and dull, lackluster eyes. The one and
only thing in common between these two classes of
" head-achers " is that their blood and tissues are loaded
with poisons. Whether produced by invading germs
or by starvation and malnutrition of the body-tissues
makes no difference to the headache nerves. Their
business, like good watchdogs, is to bark every time
they smell danger of any sort, whether it be bears or
book-agents. One of the most valuable services ren-
dered us by our priceless heads is aching.

This view of the nature of headache explains at once
why it is so extraordinarily frequent and so extraordi-
narily varied in causation. It is not too much to say
that any influence that injuriously affects the body
may cause a headache. It would, of course, be idle
even to attempt to enumerate the different causes and
kinds of this pain, as it would involve a review of the
entire environment of the human species, internal and

374 PREVENTABLE DISEASES

external. It makes not the slightest difference how the
poison gets into the blood, or where it starts. A piece
of tainted meat or a salad made from spoiled tomatoes
will produce a headache just as promptly and effec-
tively as an over-exposure to the July sun or an attack
of influenza. It is even practically impossible to pick
out from such a wealth of origins two or three, or even
a score of, conditions which are the most frequent,
most important, or the most interesting causes. The
most exasperating thing about dealing with a head-
ache is that we never know, until its history has been
most carefully examined, whether we have to do with
a mere temporary expression of discomfort and un-
balance, due to overfatigue, errors in diet, a stuffy room,
lack of exercise, or what-not, which can be promptly
relieved by removing the cause ; or whether we have to
deal with the first symptoms of a dangerous fever, the
beginning of a nervous breakdown, or an early warn-
ing of some grave trouble in kidneys, liver, or heart.

The one thing, however, that stands out clearly is
that headache always means something ; that it should
be promptly and thoroughly investigated with a view
to finding and removing the cause, — never as some-
thing which is to be cured as quickly as possible, as the
police cure social discontent, by clubbing it over the
head, with some narcotic or other symptom-smotherer.
Nor should it be regarded as a malady so trifling that
it is best treated with contempt, and still less as a mere
"thorn in the flesh," whose ignoring is to be counted
a virtue, or whose patient endurance without sign a
mark of saintship. Martyrdom is magnificent when it

HEADACHE 375

is necessary, but many forms of it are sheer stupidity.
Don't either gulp down some capsule, or "grin and
bear it." Look for the cause. The more trivial it is,
the easier it will be to discover and remove before seri-
ous harm has been done. The less easy you find it to
put your finger upon it, the more likely it is to be serious
or chronic, and the more necessary it is to remove it.

Once, however, we have clearly recognized that no
headache should be treated too lightly or indifferently,
it may be frankly admitted that practically the vast
majority of headaches in which we are keenly interested
— that is, the kind that we individually or the members
of our family habitually indulge in — do form a mod-
erately uniform class among the hundreds of varieties,
and are in the main due to some six or seven great
groups of causes. We have learned by repeated and
unpleasant experience that they are very apt to " come
on" in about a certain way, after a certain set of cir-
cumstances; that they last about so long, that they
are made worse by such and such things, that they are
helped by other things, and that they generally get
better after a good night's sleep.

One of the commonest causes of this group of re-
current and self-limited headaches is fatigue, whether
bodily, mental, or emotional. This was long an appar-
ent stumbling-block in the way of a poison theory of
headache, but now it is one of its best illustrations.
Physiologists years ago discovered that what produced
not merely the sensation but also the fact of fatigue, or
tiredness, was the accumulation in the muscles or
nerves of the waste-products of their own activities.

376 PREVENTABLE DISEASES

Simply washing these out with a salt solution would
start the utterly fatigued muscle contracting again,
without any fresh nourishment or even period for rest.
It has become an axiom with physiologists that fatigue
is simply a form of self -poisoning, or, as they sonorously
phrase it, autointoxication. One of the reasons why
we are so easily fatigued when we are already ill, or,
as we say, " out of sorts," is that our tissues are already
so saturated with waste-products or other poisons
that the slightest addition of the fatigue poisons is
enough to overwhelm them. This also explains why
our pet variety of headache, which we may have clearly
recognized to be due to overwork or overstrain of
some sort, whether with eye, brain, or muscles, is so
much more easily brought on by such comparatively
small amounts of overexertion whenever we are already
below par and out of sorts. People who are "born
tired," who are neurasthenic and easily fatigued and
" ached," are probably in a chronic state of self -poison-
ing due to some defect in their body-chemistry. Fur-
ther, the somewhat greater frequency and acuteness of
headache in brain workers — although the difference
between them and muscle workers in this regard has
been exaggerated — is probably due in part to the
greater sensitiveness of their nerves ; but more so to the
curious fact, discovered in careful experiments upon
the nervous system, that the fatigue products of the
nerve-cells are the deadliest and most powerful poisons
produced in the body. Hence some brain workers can
work only a few half-hours a day, or even minutes at
a time ; for instance, Darwin, Spencer, and Descartes.

HEADACHE 377

A very frequent cause of these habitual headaches,
really a subdivision of the great fatigue group, is eye-
strain. This is due to an abnormal or imperfect shape
of the eye, which is usually present from birth. Hence,
the only possible way of correcting it is by the addition
to the imperfect eye of carefully fitted lenses or spec-
tacles which will neutralize this mechanical defect. To
put it very roughly, if the eye is too flat to bring the
light-rays to a focus upon the retina, which is far the
commonest condition (the well-known "long sight,"
or hyperopia), we put a plus or bulging glass before
the eye and thus correct its shape. But if the eye is
too round and bulging, producing the familiar " short
sight," or myopia, we put a minus or concave lens
before the eye, and thus bring it back to the normal.
By a curious paradox, however, it often happens that
the headache due to eyestrain is caused not by the
grosser defects, such as interfere with vision so seri-
ously as absolutely to demand the wearing of glasses
to see decently, but from slighter and more irregular
degrees and kinds of misshapenness in the eye, most
of 'which fall under the well-known heading of astig-
matism. These interfere only slightly with vision, but
keep the eye perpetually on the strain, on a twist, as it
were, rasping the entire nervous system into a state of
chronic irritation. Our motto now, in all cases of
chronic headache, is, first examine the patient's habits
of life, next his eyes.

Many forms of headache are really stomach-ache
in disguise, due to digestive disturbances, the absorp-
tion of poisons from the food-tube, whether from

378 PREVENTABLE DISEASES

tainted, spoiled, or decayed foods, as in the now fa-
miliar ptomaine poisoning, or from imperfect pro-
cesses of digestion. The immediate effect, however, of
diet in the causation of headache is not so great as
we once believed. We have no adequate basis for be-
lieving that any particular kinds or amounts of food
are especially likely to produce either headache or
what we might call the headache habit, except in so
far as they upset the digestion. In a certain number
of susceptible individuals, however, it will be found
that some particular kind of food, often perfectly whole-
some and harmless in itself, will bring on an attack of
headache whenever it is indulged in. Very frequently
the disturbances of digestion which are put down as the
cause of a headache are only symptoms of some general
constitutional lack of balance, as eyestrain or neuras-
thenia, which is the cause of both these discomforts.
Far fewer headaches can be cured by dieting than we
at one time believed, and underfeeding is a more fre-
quent cause than overeating.

By an odd boukversement the one type of headache
which we have almost unanimously in the past attri-
buted to digestive disturbances, the famous, or, rather,
infamous, "sick headache," is now known to have
little or nothing to do with the stomach in its origin. In
fact, incredible as it may seem at first sight, it is the
headache that causes the sickness, not the sickness
the headache. Stop the pain of a sick headache in the
early stage, and the sickness will never develop at
all. The vomiting of sick headache is an interesting
illustration of vomiting due to disturbances of the brain

HEADACHE 379

and nervous system, technically known as central
vomiting. Another illustration is the vomiting of sea-
sickness, due solely to dizziness from the gross con-
tradiction between the testimony of our eyes and of the
balancing canals in the inner ear. The stomach or its
contents has no more to do with seasickness than the
water in a pump has with the plunger. Injuries to the
head will bring on severe and uncontrollable vomiting,
and the severer type of fevers is very frequently ushered
in by this curious sign. As to what it means, we are
as yet utterly in the dark, for in none of these condi-
tions does the process do the slightest good, but simply
adds to the discomfort of the situation. It would appear
to be a curious echo of ancestral times, when the animal
was pretty much all stomach, and hence emptying that
organ would probably relieve two-thirds of his dis-
comforts. Whatever the explanation, the fact re-
mains that whenever our nervous system gets about
so panic-stricken, it promptly begins throwing its cargo
overboard, in the blind hope that this may somehow
relieve the situation. The bile that we bring up at the
end of these interesting acrobatic performances and
which makes us feel so much better, — because we
have now got the cause of the trouble out of our system,
— is simply due to the prolonged vomiting, which has
reversed the normal current and caused the perfectly
healthy bile from our unoffending liver to pass upward
into the stomach, instead of downward into the bowels.
In another great group of headaches natural poisons
or waste-products are not burned up or got rid of
through the body-sewers and pores as rapidly as they

380 PREVENTABLE DISEASES

should be; for instance, the familiar headache from
sitting too long in a stuffy room. Your well-known
and well-earned discomfort is, of course, due in part
to the irritating and often poisonous gases, dust, and
bacteria, which are present in the air of an unventi-
lated room ; but it is also due to the steady piling up of
the waste products of your own tissues. These poisons
are normally oxidized in the muscles, burned up and
exhaled through the lungs, and sweated out through
the skin, — all three of which relief agencies are, of
course, practically paralyzed, or working at lowest
possible level, while you are sitting at your desk.

The well-known headache of sluggish bowels is an
obvious case in point; and one of the early signs of
beginning failure of the kidneys, as in Bright's disease,
is a headache of a peculiar type due to accumulation in
the system of the poisons which it is their duty to get
rid of.

There are few things the head resents more keenly
than loss of sleep. The pillow is the best headache
medicine. If this loss of sleep be due to the encroach-
ments of work or of amusements, then the mechanism
of its production is obvious. The fatigue poisons pro-
duced during the day and normally completely neu-
tralized and burned up during sleep are not entirely
disposed of and remain in the tissues to torture the
nerves. The headache of insomnia, or habitual sleep-
lessness, on the other hand, is not, strictly speaking,
caused by loss of sleep. Paradoxical as it may sound,
the fatigue poisons, which in moderate amounts wTill
produce drowsiness and promote sleep, in excessive

HEADACHE 381

amounts will cause wakefulness and inability to sleep.
Insomnia and headache are usually symptoms of this
overfatigued, or poisoned, condition, and should both
be regarded and treated as symptoms by the removal
of their causes, not by the use of coal-tar products and
hypnotics.

Another common cause of headache is nasal ob-
struction, such as may be due to adenoids or deformities
of the septum, or chronic catarrhal conditions. These
probably act by their interference with breathing and
consequent imperfect ventilation of the blood, as well
as by obstruction and, inflammation of the great air-
spaces in the bones of the skull, closely underlying the
brain, which open and drain into the nose.

It may be remarked in passing that " sick headache,"
or migraine, though long and painfully familiar to us,
is still a puzzle as to its cause. But the view which
seems to come nearest to explaining its many eccen-
tricities is that it is usually due to a congenital defect,
not so much of the nervous system as of the entire
body, by which the poisons normally produced in its
processes fail to be neutralized and got rid of, and
gradually accumulate until they saturate the system
to such a degree as to produce a furious explosion of
pain. This defect may quite possibly be in one of the
ductless glands or in some of the internal secretions,
rather than in the nervous system.

Obviously, after what has been said of the wo rid-wide
causation of headache, to attempt to discuss its treat-
ment would be as absurd as to undertake to advise
what should be done for the relief of hunger, for " that

382 PREVENTABLE DISEASES

tired feeling," or for a pain in the knee. The treatment
for a headache due to an inflammation or tumor of the
brain would, of course, be wide as the poles from that
which would relieve an ordinary fatigue or indigestion
pain. Besides, it is utterly irrational and often harmful
to attempt to treat any headache as such. That is the
open road to the morphine habit and drug addictions
of all sorts. Remedies — and there are plenty of them
— which simply relieve the pain without doing any-
thing to remove its cause, merely make the latter
state of that individual worse than the first. Headache
is always and everywhere nature's vivid warning that
something is going wrong, like the shrieking of a wagon-
axle or the clatter of a broken cog in machinery.

There is, however, fortunately one remedy which
alone will cure ninety-nine per cent of all headaches,
and that is rest. The first thing an intelligent ma-
chinist does when squeaking or rattling begins is to
stop the machinery. This has the double advantage
of preventing the damage from going any further and
of enabling him to get at the cause. Headache, like
pain anywhere, is nature's imperative order to Halt,
at least long enough to find out what you are doing
to yourself that you should n't. It makes little differ-
ence what you take for your headache, so long as you
follow it up by lying down for an hour or two, or, better
still, by going to bed for the remainder of the day
and sleeping through until the next morning. If more
headaches were treated in this way there would not
only be fewer headaches, but two-thirds of the risks
of nervous breakdown, collapse, insomnia, and chronic

HEADACHE 383

degenerative changes in the liver, kidneys, and blood-
vessels would be avoided.

This, of course, is a counsel of perfection, and in-
capable of general application for the sternest of rea-
sons; but it does indicate the rational attitude toward
headache and its treatment, and one which is coming
to be more and more adopted. No motorist would
dream of pushing ahead with a shrieking axle or a
scorching hot box, unless his journey were one of most
momentous importance or a matter of life and death.
Pain is nature's automatic speed regulator. It is often
necessary to disregard it, to get the work of the world
done and to discharge our sacred obligations to others ;
but this disregarding should not be exalted to too high
a pinnacle of virtue, and least of all worshiped as in-
herently and everywhere a mark of piety and one of the
insignia of saintship.

A business firm or a factory, for instance, which
would send home for the day each of its employees
who reported a genuine case of bad headache, would,
in the long run, save money by avoiding accidents,
mistakes, muddles, and confusions, often involving
a whole department, due to the kind of work that is
done by a man or woman who is physically unfit to
attempt it. And the higher the type of work that has
to be done, the more the elements of insight, grasp, and
sound judgment enter into it, the graver and costlier
are the mistakes that are likely to be made under such
circumstances.

Of course, it will probably be objected at this point :
" What is the use of wasting a day, or even half a day,

384 PREVENTABLE DISEASES

when by taking two or three capsules of So-and-So's
Headache Cure I can get rid of the pain and go right
on with my work?" It is perfectly true that there are
a number of remedies which will relieve the average
headache; but there are two important things to be
borne in mind. The first is that all of these are simply
weaker or stronger nerve-deadeners ; most of them
actual narcotics. All that they do is to stop the pain and
thus cheat you into the impression that you are better.
You are just as tired and as unfit for work as you were
before. Your nervous system is just as saturated with
poisons, and the chances are ten to one that the quality
of the work that you do will be just as bad as if you had
taken no medicine. Further, like alcohol, when used
as a " pick-me-up " under somewhat similar conditions,
the remedy which you have taken, while producing
a false sense of comfort and even exhilaration by dead-
ening your pain and discomfort, in that very process
itself takes off the finer edge of your judgment, the
best keenness of your insight, and the highest balance
of your control. In short, your nervous system has to
struggle with all the poisons that were present before,
with another one added to them !

After you have taken nature's wise advice, and
obeyed her orders, and put yourself at rest, then there
are a number of mild sedatives, with which every
physician is familiar, one of which, according to the
special circumstances of your case, it may be perfectly
legitimate to take in moderate doses, with the approval
of a physician, as a means of relieving the pain and
helping to get that sleep which will complete the cure.

HEADACHE 385

One other measure of relief, which, like rest, is also
indicated by instinct, is worth mentioning, and that is
gentle friction of the head. One of the most instinctive
tendencies of most of us when suffering from a severe
headache is to put the hands to the head, either for the
purpose of frantically clutching at it, rubbing as if our
lives depended upon it, or pressing hard over the aching
region. The mere picture of a man with his head in his
hands instantly suggests the idea of headache. Part
of this is, of course, little more than a blind impulse to
do something to or with the offending member. We
would sometimes like^to throw it away if we could, or
at others to bang it against the wall. But part of it is
due to the discovery, ages ago, that pressure and fric-
tion would give a certain amount of relief.

For some curious reason the nerves most frequently
involved are those which are most readily accessible
for this kind of treatment, namely, the long nerve-
threads which run from the inner third of the eyebrow
up the forehead and over the crown of the head (the
so-called supraorbital or frontal branches). A corre-
sponding pair run up the back of the neck, about half-
way between the back of the ear and the spinal column,
supplying the back of the head and the crown (these
form the cervical plexus) ; and a smaller pair run up
just in front of the ear into the temple, and from there
on upward to join the other two pairs at the top of the
head.

Broadly speaking, the position of the pain depends
upon which pair of these nerves is lifting up its voice
most vigorously in protest. If it be the front pair

386 PREVENTABLE DISEASES

(supraorbitals) then we get the well-known frontal
or forehead headache ; if the back pair (known as the
occipitals) then we have the deadly, constricting, band-
around-the-head pain which clutches us across the
back of the neck and base of the brain. If the lateral
pair are chiefly affected then we get the classic throb-
bing temples. Practically all of these aches, however,
are of the "fire-alarm" character; and while certain
of these nerve-gongs show some tendency to respond
more readily to calls coming in from certain regions
of the body, as, for instance, the forehead nerves to eye-
strain, the back-of-the-head nerves (occipital) to grave
toxic states of the system, the tips of any of the nerves
in the crown of the head to pelvic disturbances and
anaemic conditions, the lateral branches in the temples
to diseases of the teeth and throat, yet there is little
fixed uniformity in these relations. Eyestrain, for
instance, may cause either frontal or occipital head-
ache; and, as every one knows from experience, the
pain may be felt in all parts of the head at once.

Gentle and intelligent massage over the course of
these nerves of the scalp, according to the location of the
pain, will often do much to relieve the severity of the
suffering.

Treat headache as a danger signal, by rest and the
removal of its cause, and it will prevent at least ten
times as much suffering and disability as it causes.

CHAPTER XVIII

NERVES AND NERVOUSNESS

NERVES are real things. In spite of their con-
nection with imaginary diseases and mental dis-
turbances, there is nothing imaginary or unsubstantial
about them. There is no more genuine and obstinate
malady on earth than a nervous disease. Because
nerves lie in that twilight borderland between mind
and matter, body and soul, the real and the ideal, the
impression has got abroad that they are little better
than figures of speech. Though their disturbances give
rise to visions of all sorts there is nothing visionary
about them; they are just as genuine and substantial
a part of our bodily structure as our bones, muscles,
and blood-vessels. In fact, it was this very substan-
tiality that at the beginning prevented their proper
recognition, and handicapped them with their present
absurd and inappropriate name.

" Nerve" is from the Greek neuron, meaning tendon,
or sinew, and was originally applied indiscriminately
to all the different shining cords which run down the
limbs and among the muscles. In fact the first recog-
nition of nerves was an utter failure to recognize. The
tendon cords, which are the ropes with which the
muscles work the joint pulleys, were actually included
under one head with the less numerous but almost
equally large and tough cords of grayer color, flatter

388 PREVENTABLE DISEASES

outline, and less glistening hue, which were afterwards
found to be nerve-trunks. Cutting either paralyzed
the limb below the cut, — and what more proof could
you ask of their having the same function ?

Such is the persistence of ancient memories, that
any physician could tell you of scores of cases in which
he has heard the naive remark, in reference most fre-
quently to a deep gash across the wrist, that the
"nerves" were cut, and the hand was paralyzed, when
what had happened was simply that the tendons had
been cut across. When, after centuries of blundering
in every possible direction until the right one was
finally stumbled upon (which is the mechanism of pro-
gress), it was realized that some of these " nerves," the
grayer and flatter ones, carried messages instead of
pulling ropes, they were still far from being properly
understood.

It is an amusing illustration of the blissful ignorance
and charming naivete which marked their study and
discussion at this time, that nerves were for centuries
regarded as hollow tubes, carrying a supply of " animal
spirits" from the central reservoir of the brain to the
different limbs. So seriously was this believed, that,
in amputations, the cut nerve-trunks were carefully
sought out and tied, for fear the vital spirits would leak
out and the patient thus literally bleed to death. One
can imagine how this must have added to the comfort
of the luckless patient.

The term "nerves" still persists, in the old sense,
in both botany and entomology, which speak of the
"nerves" of a butterfly's wing, or the "nervation" of

NERVES AND NERVOUSNESS 389

a leaf, meaning simply the branching, fibrous frame-
work of each.

It comes in the nature of a surprise to most of us to
learn that "nerves" are real things. I shall never for-
get the shock of my own first convincing demonstration
of this fact. It was in one of the first surgical clinics
that I attended as a medical student. A woman patient
was brought in, with a history of suffering the tortures
of the damned for a year past, from an uncontrollable
sciatica.

It was a recognized procedure in those days (and is
resorted to still) , when all medical, electrical, and other
remedial measures had failed to relieve a furious
neuralgia, for the surgeon to cut down upon the nerve-
trunk, free it from its surrounding attachments, and,
slipping his tenaculum or finger under it, stretch the
nerve with a considerable degree of force. Whether
it acts by merely setting up some trophic change in
the nerve-tissue, or by tearing loose inflammatory
adhesions which are binding down the nerve-trunk,
the procedure gives excellent results, nearly always
temporary relief, and sometimes a permanent cure.

The patient was placed upon the table and anaes-
thetized, and the surgeon made a free, sweeping in-
cision down the back of the thigh, exposing the sciatic
nerve. He thrust his finger into the wound, loosened
up the adhesions about the nerve, hooked two fingers
underneath it, and, to my wide-eyed astonishment,
heaved upward upon it, until he brought into view
through the gaping wound a flattened, bluish-gray
cord about twice the size of a clothesline, with which

390 PREVENTABLE DISEASES

he proceeded to lift the hips of the patient clear of the
table. In my ignorant horror, I expected every moment
to see the thing snap and the patient go down with a
bump, paralyzed for life; but I never doubted after
that that nerves were real things. Though it has
nothing to do with this discussion, for the benefit of
those of my readers who cannot bear to have a story
left unfinished, I will add that the operation was as
successful as it was dramatic, and the patient left the
hospital completely relieved of her sciatica.

When at last it was clearly recognized that the nerves
were concerned in the sending of messages from the
centre to the brain, known as sensory, or centripetal,
and carrying back messages from the brain to the mus-
cles and surface, known as motor, or centrifugal, — in
other words that they were the organs of the mind, —
still another source of confusion sprang up, and that
was the determination on the part of some to regard
them from a purely mental and, so to speak, spiritual
point of view, and on the part of others to regard
them from a physical and anatomical point of view.
This confusion is of course in full riot at the present
time.

The term "nerves," and its adjective, "nervous,"
are used in two totally distinct senses : one, that which
is vague and unsubstantial, purely mental or sub-
jective, and, in the realm of disease at least, imaginary;
the other, purely anatomical, referring to certain
strands of tissue devoted to the purpose of transmitting
impulses, and the condition affecting these strands.
I am not so rash as to raise the question here, — still

NERVES AND NERVOUSNESS 391

less to attempt to settle it, — which of these two views
is the right and rational one. Whether the brain secretes
thought as the liver does bile, or whether the mind
created the brain and nervous system, or, as it has been
epigrammatically put in a recent work on psychology,
" whether the mind has a body, or the body has a mind,"
I merely call attention to the fact that this confusion
of meanings exists, and that its injection into the field
of medicine and pathology, at least, has done an enor-
mous amount of harm in the way of confusing problems
and preventing a proper recognition of the actual facts.

The more carefully and exhaustively and dispas-
sionately we study the disorders of the nervous system
which come in the field of medicine, the more irre-
sistibly we are drawn to the conclusion that from
neurasthenia and hysteria to insanity and paralysis
they are every one of them the result of some definite
morbid change in some cell or strand of the nervous
system. The man or woman who is nervous has
poisoned nerve-cells, either from hereditary defect,
or direct saturation of the tissues with toxic substances.
The patient who has an imaginary disease is suffering
from some kind of a hallucination produced by poison-
soaked nerve-cells, such as in highest degree give
rise to the delirium of fevers, and the horrid spectres
of delirium tremens.

Even the man who is suffering from a "mind dis-
eased," and confined in one of our merciful asylums
for the insane, is in that condition and position on
account of physical disease, not merely of his brain,
but of his entire body. The lunatic is insane, in the for

392 PREVENTABLE DISEASES

once correct derivative sense of unhealthy, to the very
tips of his fingers. Not merely his mind and his brain,
but his liver, his stomach, his skin, his hair and finger-
nails, the very sweat-glands of his surface which con-
trol his bodily odor, are diseased arid have been so
usually for years before his mind breaks down.

Tell a competent expert to pick out of a crowd of
a thousand men and women the ten who are likely to
become insane, and his selection will be found almost
invariably to include the two or three who will actually
become so.

In fact, from even the crudest and scantiest know-
ledge of the actual growth of our own bodies from the
ovum to the adult, it will be difficult to conceive how
this relation could be otherwise, The nerve-cells and
their long processes, which form the nerve-trunks, are
simply one of a score of different specialized cells
which exist side by side in the body. Primarily all
our body-cells had the power of responding to stimuli,
of digesting and elaborating food, of moving by con-
traction, of reproducing their kind. The nerve-cells
are simply a group which have specialized exclusively
upon the power of receiving and transmitting impulses.
They still take food, but it has to be prepared for them
by the other cells ; and here, as we shall see later, is one
of the dangers to which they are exposed. They still
reproduce their kind, but in very much smaller and
more limited degree. They still, incredible as it may
seem, probably have slight powers of movement or
contraction, and can draw in their processes. But they
have surrendered many of their rights and neglected

NERVES AND NERVOUSNESS 393

some of their primitive accomplishments, in order to
devote themselves more exclusively and perfectly to
the carrying out of one or two things.

In spite of all this, however, they still remain blood-
brothers and comrades to every other cell in the body.
In the language of Shylock, " If you cut them, they
will bleed ; if you tickle them, they will laugh ; if you
starve them, they will die." In all this development,
which continued up to a late hour last night, and is
still going on, the nerve-tissue has lain side by side
with every other tissue in the body, fed by the same
blood, supplied with the same oxygen, saturated with
the same body- lymph'

It is of course perfectly clear that any influence,
whether beneficial or injurious, affecting the body,
will also be likely to affect the nervous system, as a part
of it; and this is precisely the fact, as we find it. If
the body be well fed, well warmed, sufficiently exer-
cised, without being overworked, and allowed a liberal
allowance of that recharging of the human battery
which we call sleep, then the nervous system will
work smoothly and easily, at peace with itself and with
all mankind. Its sense-organs will receive external
impressions promptly and accurately. Its conducting
fibres will transmit them to the centre with neither de-
lay nor friction. The brain clearing-house will receive
and dispose of them with ease and good judgment.
And then, just because his nervous system is working
to perfection, we say that such an individual " has no
nerves."

If the triumph of art be to conceal art, then the

394 PREVENTABLE DISEASES

nerves have achieved this. They have literally effaced
themselves in the well-being of the body.

If on the other hand, the food-supply is inadequate,
if the sleep allowance has been cut short, whether by
the demands of work or by those of fashion, if the body
has been starved of oxygen and deprived of sunlight,
if the whole system has been kept on the rack, whether
in the sweatshop, or in the furnace of affliction, what
is the effect on the nervous system ? Just what might
have been expected. The sense-organs shy, like a fright-
ened horse, at every shadow or fluttering leaf. The
conducting wires break, and cross, and tangle in every
imaginable fashion. The central exchange, half wild
with hunger, or crazed with fatigue-toxins, shrieks
out as each distorted message comes in, or sulks be-
cause it can't understand them. And then, with charm-
ing logicality, we declare that such an one is "all
nerves."

The brain, by which we mean the biggest one near
the mouth, — we have little brains, or ganglia all over
our bodies, — so far from being an absolute monarch,
is not even a constitutional one, or a president of a
republic, but a mere house of congress of the modern
type, which can do little but register and obey the
demands of its constituents. The brain originates
nothing. Impulses are brought to it from the sense-
organs by the nerves. They set up in it certain vibra-
tions, or chemical disturbances. It responds to these
much as blue litmus paper turns red when a weak acid
is dropped on it, or as lemonade fizzes when you put
soda in it. If more than one of these vibrations are

NERVES AND NERVOUSNESS 395

set up simultaneously, it " chooses " between them,
by responding to the strongest. If the response differs
from the stimulus, it is because of its huge deference
to precedent as established by the records of previous
stimuli with which its tissues are stored.

This brings us to the interesting and important ques-
tion, What are the causes of these disturbances of the
nerve-tissues ? Probably the most important single re-
sult that has been reached in our study of nervous dis-
eases in the last fifteen years, is that the cause of them
in easily eighty per cent of all cases lies entirely out-
side of the nervous system.

The stomach burns, the nerve-tissues send in the
fire alarm and order out the engines. The liver goes
on a strike, and the body-garbage, which it has failed
to burn to clean ashes and clear smoke, poisons the
nerve-cells, and they remonstrate accordingly, on be-
half of the other tissues. The heart, or blood-vessels,
fails to supply a certain muscle with its due rations of
blood and the nerves of the region cry out in the agony
of cramp.

We have discovered, by half a century of careful
study in the hospital and in the sick-room, not only
that the nerve-tissues are usually poisoned by defect
of other tissues of the body, but that they are among the
very last of the body-stuffs to succumb to an intoxica-
tion. The complications of a given disease involving
the nervous system are almost invariably the last of
all to appear. This is one of the things that has given
nervous diseases such a bad name for unmanageable-
ness and incurableness, and that for years made us

396 PREVENTABLE DISEASES

regard their study as so nearly hopeless, so far as any
helpful results were concerned.

When a disease has, so to speak, soaked into the in-
most core of the nerve-fibre, it has got a hold which it
will take months and even years to dislodge. And be-
fore your remedies can reach it, it will often have done
irreparable damage. An illustration of the care taken
to spare the nervous system is furnished by its be-
havior in starvation. If a man or an animal has almost
died of starvation, the tissues of the body will be found
to have been wasted in very varying degrees, the fat,
of course, most of all ; in fact this will have almost en-
tirely disappeared, all but three per cent. Then come
the liver and great glands, which will have shrunk about
sixty per cent ; then the muscles, thirty per cent ; then
the heart and blood-vessels. Last of all, the nervous
system, which will scarcely have wasted to any appre-
ciable degree. In fact, it is an obvious instance of
jettison on the part of the body, throwing overboard
those tissues which it could most easily spare, and
hanging on like grim death to those which were ab-
solutely essential to its continued existence, viz., the
heart and the nervous system. To use a cannibalistic
and more correct illustration, it is killing and eating
the less useful and valuable members of its family, in
order that their flesh may keep alive the two or three
most indispensable.

Another illustration is the actual behavior of the
nerve-stuff in disease. This is most clearly shown
in those clear-cut disturbances which are definitely
known to be due to a specific infection; in other

NERVES AND NERVOUSNESS 397

words, invasion of the body by a disease-organism, or
germ.

First of all, it may be stated that physicians are now
substantially agreed that two-thirds of the general
diseases of the nervous system are due to the extension
of one of these acute infections to the nerve-tissue ; and
this extension almost invariably comes late in the dis-
ease. The only exceptions to this rule in the whole list
of infectious diseases are two, epidemic cerebro-spinal
meningitis (spotted fever), and tetanus (lockjaw).
Both of these have an extraordinary and deadly pre-
ference for the nervous system from the very start, and
this is what gives them their frightful mortality and
discouraging outlook. Even of this small number of
exceptions, we are not altogether certain as to epi-
demic meningitis, inasmuch as we do not know how
long the germ may have existed in the other tissues
of the body before it succeeded in working its way to
and attacking the brain and spinal cord.

The case of tetanus, however, is perfectly clear in
this regard, and exceedingly interesting, inasmuch
as it explains why a disease specially involving the ner-
vous system from the start is so excessively hard to
check or cure. The germ of the disease, long ago iden-
tified as one having its habitat in farm or garden soils,
— particularly those which have been heavily fertilized
with horse manure, — gets into the system through
a cut or scratch upon the surface, into which the soil
is rubbed. These infected cuts, for obvious reasons,
are most frequently upon the hands or feet.

Small doses of the organism have been injected into

398 PREVENTABLE DISEASES

animals ; then, when they have recovered, larger ones,
and so on, after the manner of the bacillus of diphtheria,
until a powerful antitoxin can be obtained from their
blood, very minute quantities of which will promptly
kill the bacilli in a test-tube. For seven or eight years
past we have been injecting this into every patient
with tetanus that came under our observation, but so
far with very limited benefit, even though the injections
were made directly into the spinal cord, or brain
substance. The problem puzzled us for years, until
finally Cattani stumbled upon the explanation. While
we had been supposing that the poison was carried,
as almost every other known poison is, through the
blood-vessels, or lymph-channels, to the heart and
thence to the brain, he clearly proved that it ran up the
central axis of the nerve- trunks, and consequently,
when it had got once fairly started up this channel,
was as safe from the attack of any antitoxin merely
present in the general circulation and fluids of the
body, as the copper of the Atlantic cable is from the
eroding action of the sea-water. If, in his experimental
animals, he carefully sought for the cut end of the
nerve- trunk in the wound that had been infected, and
injected the antitoxin directly into that, the disease
was stopped. Or it might even be "headed off" by
the crude method of cutting directly across the nerve-
trunk at a point above that yet reached by the infec-
tion.

The cotmnonest and most fatal of all forms of general
diseases of the nervous system are those which are
due to the later extensions of general infections.

NERVES AND NERVOUSNESS 399

First and foremost stands syphilis, due to the in-
vasion of the blood by a clearly defined spirillum, the
Treponema pallida of Schaudinn. This first attacks
the mucous membranes of the throat and mouth, then
the skin, then the great internal organs like the liver
and stomach, then the bones, and, last of all, the ner-
vous system. The length of time which the poison
takes to reach the nervous system is something which
at first sight is almost incredible, viz., from one and a
half to fifteen years. It is true that in rare instances
brain symptoms will manifest themselves within six
or eight months ; but these are usually due to pressure
by inflammatory growths on the bones of the skull and
its lining membrane (dura mater) . It is not too much
to say that this disease plays the greatest single role in
nervous pathology. Three of the commonest and most
fatal diseases of the spinal cord and brain, paresis
(general paralysis of the insane) , locomotor ataxia, and
lateral sclerosis, are due to it.

Naturally, when a poison has taken a decade or a
decade and a half to penetrate to the nerve-tissues, it
does irreparable damage long before it can be dis-
lodged or neutralized.

A similar aftermath may occur in almost all of the
acute infectious diseases. Every year adds a new
one to the list capable of causing cerebral complica-
tions. Tuberculosis, diphtheria, scarlet fever, typhoid,
smallpox, influenza, have now well-recognized cerebral
and nervous complications, some temporary, some
permanent. A form of tuberculosis attacking the cover-
ings (meninges) of the brain — hence known as men-

400 PREVENTABLE DISEASES

ingitis — is far the commonest fatal brain-disease of
infancy and childhood.

Perhaps the most striking illustration of just how
acute affections attack the nervous system, is that
furnished by diphtheria. A child develops an attack
of this disease, passes the crisis safely, and begins to
recover. A few days later, it is allowed to sit up in bed.
Suddenly, after some slight exertion, or often without
any apparent cause, the face blanches, the eyes stare
widely, the child gasps two or three times, and is dead :
sudden heart failure, due to the poisoning either of
the heart muscle itself, or of the nerves supplying the
heart, by the toxin of the disease. Moral : Keep diph-
theria patients strictly at rest in bed for at least a week
after the crisis is past. Another case will pass this
period safely, though perhaps with a rapid and weak
heart, for days or weeks; then one morning the child
will choke when swallowing milk. The next time it is
attempted, the milk, instead of going down the throat,
comes back through the nostrils. Paralysis of the soft
palate has developed, apparently from a local satura-
tion of the nerves with the poison. This may go no
further, or it may extend, as it commonly does, to the
nerves of the eye, and the child squints and can no
longer read, if old enough, because the muscle of ac-
commodation also is paralyzed. The arms and limbs
may be affected, and in extreme cases the nerves of res-
piration supplying the diaphragm may be involved,
and the child dies of suffocation. In the majority of
cases, however, fortunately, after this paralysis has
lasted from three to six weeks, it gradually subsides,

NERVES AND NERVOUSNESS 401

and may clear up completely, though not at all infre-
quently one or more muscles may remain permanently
damaged by the attack, giving, for instance, a palatal
tone to the voice, or interfering with the production of
singing tones. Occasionally a permanent squint may
follow.

It might be said in passing, that, with one of the
charming logicalities of popular reasoning, these nerve
complications have been said to be caused by antitoxin,
simply because the use of the antitoxin saves more
children alive to develop them.

The next group of nervous diseases may be roughly
described as due to the failure of some part of the di-
gestive system, like the stomach and intestines, properly
to elaborate its food ; or of one of the great glands, like
the liver, thyroid, or suprarenal, properly to supply
its secretion, which is needed to neutralize the poisons
normally produced in the body. This class is very
large and very important. It has long been known how
surely a disordered liver "predicts damnation";
melancholia; or "black bilious condition," hypochon-
dria, or " under the rib-cartilages " (where the liver
lies) , are every-day figures of speech. A thorough house-
cleaning of the alimentary canal, together with proper
stimulation of the skin and kidneys, and an intelligent
regulation of diet, are our most important measures
in the treatment of diseases of the nervous system, even
in those extreme forms known as insanity.

Closely allied to these are those disturbances of the
nervous system lumped together under the soul-satis-
fying designation of "neurasthenia," which are chiefly

402 PREVENTABLE DISEASES

due to the accumulation in the system of the fatigue
poisons, or substances due to prolonged overstrain,
under-rest, or underfeeding of the system. Neuras-
thenia is the "fatigue neurosis," as a leading expert
terms it. It may be due to any morbid condition under
heaven. It is "that blessed word Mesopotamia" of the
slipshod diagnostician. Nearly one-fourth of the cases
which come into our sanatoria for tuberculosis have
been diagnosed and treated for months and even years
as "neurasthenia." It satisfies the patient — and it
means nothing; though some experts contend for a
distinct disease entity of this name but admit its
rarity.

The intelligent neurologist, nowadays, has practi-
cally no known specific for any form of nervous disease,
no remedy which acts directly and curatively upon the
nervous system itself. He relies chiefly — and this
applies to the asylum physician also — upon intestinal
antisepsis, upon rest, upon baths, upon regulation
diet, and habits of life.

A number of the more sudden and fatal disturbances
of the nervous system, as for instance, the familiar
" stroke of paralysis," or apoplexy, of later middle life,
are due to a defect, not in the nervous system at all, but
in the blood-vessels supplying the brain ; rupture of a
vessel, and consequent escape of blood, destroys so
much of the surrounding brain-tissue as to produce
paralysis, and, in extreme cases, death. Just why the
blood-vessels of the brain in general, and of one part
of the basal ganglia in particular (the Lenticulo-
striate artery in the internal capsule of the corpus

NERVES AND NERVOUSNESS 403

striatum, the old jaw ganglion) , are so liable to rupture
we do not know; but it certainly is chiefly from a de-
fect of the blood-vessels, and not of the brain. All of
which brings us to the following important practical
conclusions.

First of all, that every attack or touch, however
light, of "nervousness," "nerves," "imagination,"
" neurasthenia," yes, hysteria, means something. It is
the cry of protest of a smaller or larger part of the ner-
vous system against underfed blood, under- ventilated
muscles, lack of sunlight, lack of exercise, lack of sleep,
excess of work, or bad habits. In other words, it is the
danger signal, the red light showing the open switch,
and we will disregard it at our peril. Unfortunately, by
that power of esprit de corps of the entire system, known
as "pluck" or "grit," or the veto-power, physiologi-
cally termed inhibition, we may ignore and for a time
suppress the symptom, but this in the long run is just
as rational as cutting the wire that rings a fire alarm,
or blowing out the red light without closing the switch.

Nervousness is a symptom which should always
have something done for it, especially in children.
In fact, it has passed into an axiom both with intelli-
gent teachers and with physicians who have much to
do with the little ones, that crossness, fretfulness, lazi-
ness, lack of initiative, and readiness to weep, in chil-
dren, are almost invariably the signs of physical disease.
And this doctrine will apply to a considerable percent-
age of children of larger growth.

Unfortunately, one of the first and most decided
tendencies on the part of the badly fed or poisoned ner-

404 PREVENTABLE DISEASES

vous system, is to exaggerate the difficulties of the situ-
ation, and to minimize its good features. The individ-
ual " has lost his nerve," is afraid to undertake things,
shrinks from responsibility, exaggerates the difficulties
that may be in the way; hence the floods of tears, or
outbursts of temper, with which nervous children will
greet the suggestion of any task or duty, however tri-
fling. If the nervous individual has reached that stage
of maturity when she realizes that she is not merely
" naughty," but sick, then this same process applies
itself to her disease. She is sure that she is going to
die, that another attack like that will end in paralysis ;
as a patient of mine once expressed it to me, " My heart
jumps up in my mouth, I bite a couple of pieces off it,
and it falls back again." In short, she so obviously
and grossly exaggerates every symptom and phase of
her disease, that the impression irresistibly arises that
the disease itself is a fabrication. This view of her con-
dition by her family or her physician is the tragedy
of the neurasthenic.

Broadly speaking, no disease, even of the nervous
system, is ever purely imaginary. Some part of the
patient's nervous system is poisoned, or he would not
imagine himself to be sick. We can all of us find
trouble enough in some part of our complex bodily
machinery, if we go around hunting for it; but this is
precisely what the healthy man, or woman, never does.
They have other things to occupy them, and are far
more liable to run into danger by pushing ahead at full
steam, and neglecting small creakings and jarrings
until something important in the gear jams, or goes

NERVES AND NERVOUSNESS 405

snap, and brings them to a halt, than they are to be
wasting time and energy worrying over things that
may never happen.

Worry, in fact, is a sign of disease instead of a cause.
To put it very crudely, whenever the blood and fluids of
a body become impoverished below a certain degree,
or become loaded with fatigue poisons, or other waste
products above a certain point, then the nervous system
proceeds to make itself felt. Either the perceptive end-
organs become color-blind and read yellow for blue, or
are astigmatic and report oval for round ; or the con-
ducting nerve-strands tangle up the messages, or de-
liver them to the wrong centre ; or the central clearing-
house, puzzled by the crooked messages, loses its head,
and begins to throw the inkstands about, or goes down
in a sulk. In other words, the nervous system goes on
a strike. But it is perfectly idle to endeavor to treat it
with cheering words, or kindly meant falsehoods, to
the effect that " nothing is really the matter." Like any
other strike, it can be rationally dealt with only by
improving the conditions under which the operatives
have to work, and meeting their demands for higher
wages, or shorter hours.

We were accustomed at one time to divide diseases
into two great classes, organic and functional. By the
former, we meant those in which there was some posi-
tive defect of structure, which could be recognized by
the eye or the microscope ; by the latter, those diseases
in which this could not be discovered, in which, so to
speak, the machine was all right, but simply would n't
work. It goes without saying that the latter class was

406 PREVENTABLE DISEASES

simply a confession of our ignorance, and one which
is steadily and rapidly diminishing as science pro-
gresses.

If the machine won't work, there is a reason for it
somewhere, and our business is to find it out, and not
loftily to assure our patients that there is nothing
much the matter, and all they need is rest, or a little
cheerful occupation. Furthermore, the most inane
thing that a sympathizing friend or kindly physician
can do to a neurasthenic, is to advise him to take his
mind off himself or his symptoms. The utter inability
to do that very thing is one of the chief symptoms of
the disease, which will not disappear until the under-
lying cause has been carefully studied out and removed.

"Nerves," "neurasthenia," " psychasthenia," and
"hysteria," are all the names of symptoms of definite
bodily disease. The modern physician regards it as his
duty to study out and discover the nature of this dis-
ease, and, if possible, remove it, rather than to give
high-sounding, soul-satisfying names to the symptoms,
and advise the patient to " cheer up " ; which advice
costs nothing — and is worth just what it costs.

"But," some one will say at once, "if nervous dis-
eases are simply the reflection of general bodily states,
as sanitary conditions improve under civilization,
should they not become less frequent? And yet, any
newspaper will tell you that nervous diseases are rapidly
on the increase." This is a widespread belief, not only
on the part of the public, but of many scientists and a
considerable number of physicians ; but it is, I believe,
unfounded.

NERVES AND NERVOUSNESS 407

In the first place, we have no reliable statistical basis
for a positive statement, either one way or another.
Our ignorance of the precise prevalence of disease in
savagery, in barbarism, and even under civilization up
to fifty years ago, is absolute and profound. It is only
since 1840 that vital statistics of any value, except as
to gross deaths and births, began to be kept. So far as
we are able to judge from our study of savage tribes by
the explorer, the army surgeon, and the medical mission-
ary, the savage nervous system is far less well balanced
and adjustable than that of civilized man. Hysteria,
instead of occurring only in individual instances, at-
tacks whole villages and tribes. In fact, the average
savage lives in a state alternating between naive and
childish self-satisfaction and panic-stricken terror, with
their resultant cowardice and cruelty on the one hand,
and unbridled lust and delusions of grandeur on the
other. The much-vaunted strain of civilization upon
the nervous system is not one-fifth that of savagery.

Think of living in a state when any night might see
your village raided, your hut burned, yourself killed
or tortured at the stake, and your wife and children
carried into slavery. Read the old hymns and see how
devoutly thankful our pious ancestors were every day
at finding themselves alive in the morning, — " Safely
through another night," — and fancy the nerve-strain
of never knowing, when you lay down to sleep, whether
some one of the djinns, or voodoos, or vampires would
swoop down upon you before morning. Think of
facing death by famine every winter, by drought or
cyclone every summer, and by open war or secret scalp-

408 PREVENTABLE DISEASES

raid every month in the year ; and then say that the
racking nerve-strain of the commuter's time-table, the
deadly clash of the wheat-pit, or the rasping grind of
office-hours, would be ruinous to the uncivilized ner-
vous system. Certainly, in those belated savages, the
dwellers in our slums, hysteria, diseases of the imagina-
tion, enjoyment of ill health, and the whole brood of
functional nervous disturbances are just as common
as they are on Fifth Avenue.

It is not even certain that insanity is increasing. In-
sanity is quite common among savages ; just how com-
mon is difficult to say, on account of their peculiar
methods of treating it. The stupid and the dangerous
forms are very apt to be simply knocked on the head,
while the more harmless and fantastic varieties are
turned into priests and prophets and become the
founders of the earlier religions. A somewhat similar
state of affairs of course prevailed among civilized
races up to within the last three-quarters of a century.
The idiot and the harmless lunatic were permitted to
run at large, and the latter, as court and village fools,
furnished no small part of popular entertainment, since
organized into vaudeville. Only the dangerous or vio-
lent maniacs were actually shut up ; consequently, the
number of insane in a community a century ago refers
solely to this class. Hence, in every country where sta-
tistics have been kept, as larger and larger percentages
of these unfortunates have been gathered into hospitals,
where they can be kindly cared for and intelligently
treated, the number of the registered insane has steadily
increased up to a certain point. This was reached some

NERVES AND NERVOUSNESS 409

fifteen years ago in Great Britain, in Germany, in
Sweden, and in other countries which have taken the
lead in asylum reform, and has remained practi-
cally stationary since, at the comparatively low rate
of from two to three per thousand living. This limit
shows signs of having been reached in the United
States already ; and this gradual increase of recognition
and registration is the only basis for the alleged increase
of insanity under modern conditions.

It is also a significant fact that the lower and less
favorably situated stratum of our population furnishes
not only the largest number of inmates, but the largest
percentage of insanity in proportion to their numbers,
while the most highly educated and highly civilized
classes furnish the lowest. Immigrants furnish nearly
three times as many inmates per thousand to our
American asylums as the native born.

It is, however, true that in each succeeding census
a steadily increasing number and percentage of the
deaths is attributed to diseases of the nervous system.
This, however, does not yet exceed fifteen or twenty
per cent of the whole, which would be, so to speak,
the natural probable percentage of deaths due to
failure of one of the five great systems of the body:
the digestive, the respiratory, the circulatory, the
glandular, the nervous. Two elements may certainly
be counted upon as contributing in very large degree
to this apparent increase. One is the enormous saving
of life which has been accomplished by sanitation and
medical progress during the first five years of life,
infant mortality having been reduced in many instances

410 PREVENTABLE DISEASES

fifty to sixty per cent, thus of course leaving a larger
number of individuals to die later in life by the diseases
especially of the blood-vessels, kidneys, and nervous
system, which are most apt to occur after middle life.
The other is the great increase in medical knowledge,
resulting in the more accurate discovery of the causes
of death, and a more correct reporting and classifying
of the same.

In short, a careful review of all the facts available
to date leads us decidedly to the conclusion that the
nervous system is the toughest and most resisting
tissue of the body, and that its highest function, the
mind, has the greatest stability of any of our bodily
powers. Only one man in six dies of disease of the ner-
vous system, as contrasted with nearly one in three
from diseases of the lungs ; and only one individual in
four hundred becomes insane, as contrasted with from
three to ten times that number whose digestive systems,
whose locomotor apparatus, whose heart and blood-
vessels become hopelessly deranged without actually
killing them.

CHAPTER XIX

MENTAL INFLUENCE IN DISEASE, OR HOW THE
MIND AFFECTS THE BODY

ONE of the dearest delusions of man through all
the ages has been that his body is under the
control of his mind. Even if he did n't quite believe it
in his heart of hearts, he has always wanted to. The rea-
son is obvious. The qne thing that he felt absolutely
sure he could control was his own mind. If he could n't
control that, what could he control ? Ergo, if man could
control his mind and his mind could control his body,
man is master of his fate. Unfortunately, almost in
proportion as he becomes confident of one link in the
chain he becomes doubtful of the other. Nowadays
he has quite as many qualms of uncertainty as to
whether he can control his mind as about the power
of his mind over his body. By a strange paradox we
are discovering that our most genuine and lasting con-
trol over our minds is to be obtained by modifying the
conditions of our bodies, while the field in which we
modify bodily conditions by mental influence is steadily
shrinking.

For centuries we punished the sick in mind, the in-
sane, loading them with chains, shutting them up in
prison-cells, starving, yes, even flogging them. We
exorcised their demons, we prayed over them, we ar-
gued with them, — without the record of a single cure.

412 PREVENTABLE DISEASES

Now we treat their sick and ailing bodies just as we
would any other class of chronic patients, with rest,
comfortable surroundings, good food, baths, and fresh
air, correction of bad habits, gentleness, and kindness,
leaving their minds and souls practically without
treatment, excepting in so far as ordinary, decent hu-
manity and consideration may be regarded as mental
remedies, — and we cure from thirty to fifty per cent,
and make all but five per cent comfortable, contented,
comparatively happy.

We are still treating the inebriate, the habitual drunk-
ard, as a minor criminal, by mental and moral means
— with what hopeful results let the disgraceful records
of our police courts testify. We are now treating tru-
ancy by the removal of adenoids and the fitting of
glasses; juvenile crime by the establishment of play-
grounds; poverty and pauperism by good food, living
wages, and decent surroundings; and all for the first
time with success.

In short, not only have all our substantial and per-
manent victories over bodily ills been won by physical
means, but a large majority of our successes in mental
and moral diseases as well. Yet the obsession persists,
and we long to extend the realm of mental treatment
in bodily disease.

That the mind does exert an influence over the body,
and a powerful one, in both health and disease, is ob-
vious. But what we are apt to forget is that the whole
history of the progress of medicine has been a record
of diminishing resort to this power as a means of cure.
The measure of our success and of our control over

MENTAL INFLUENCE IN DISEASE 413

disease has been, and is yet, in exact proportion to the
extent to which we can relegate this resource to the
background and avoid resorting to it. Instead of
mental influence being the newest method of treatment
it is the oldest. Two-thirds of the methods of the sha-
man, the witch-doctor, the medicine-man, were
psychic. Instead of being an untried remedy, it is
the most thoroughly tested, most universal, most ubi-
quitous remedy listed anywhere upon the pages of
history, and, it may be frankly stated, in civilized
countries, as widely discredited as tested. The pro-
portion to which it survives in the medicine of any
race is the measure of that race's barbarism and
backwardness. To-day two of the most significant
criteria of the measure of enlightenment and of control
over disease of either the medical profession of a nation
or of an individual physician are the extent to which
they resort to and rely upon mental influence and
opium. Psychotherapy and narcotics are, and ever
have been, the sheet-anchors of the charlatan and the
miracle-worker.

The attitude of the medical profession toward mental
influence in the treatment of disease is neither friendly
nor hostile. It simply regards it as it would any other
remedial agency, a given drug, for instance, a bath,
or a form of electricity or light. It is opposed to it, if
at all, only in so far as it has tested it and found it in-
ferior to other remedies. Its distrust of it, so far as
this exists, is simply the feeling that it has toward half
a hundred ancient drugs and remedial agencies which
it has dropped from its list of working remedies as

414 PREVENTABLE DISEASES

obsolete, many of which still survive in household and
folk medicine. My purpose is neither to champion it
nor to discredit it, and least of all to antagonize or
throw doubt upon any of the systems of philosophy or
of religion with which it has been frequently associated,
but merely to attempt to present a brief outline of its
advantages, its character, and its limitations, exactly as
one might of, say, calomel, quinine, or belladonna.

As in the study of a drug, the chief points to be con-
sidered are : What are its actual powers ? What effects
can be produced with it, both in health and sickness ?
What are the diseases in which such effects may be
useful, and how frequent are they ? In what way does
it produce its effects, directly or indirectly ?

The first and most striking claim that is made for
mental influence in disease is based upon the allegation
that it has the power of producing disease and even
death; the presumption, of course, being that, if able
to produce these conditions, it would certainly have
some influence in removing or preventing them. Upon
this point the average man is surprisingly positive and
confident in his convictions. Popular literature and
legend are full of historic instances where individuals
have not merely been made seriously ill but have even
been killed by powerful impressions upon their imagi-
nations. Most men are ready to relate to you instances
that have been directly reported to them of persons
who were literally frightened to death. But the mo-
ment that we come to investigate these widely quoted
and universally accepted instances, we find ourselves
in a curious position. On the one hand, merely a

MENTAL INFLUENCE IN DISEASE 415

series of vague tales and stories, without date, lo-
cality, name, or any earmark by which they can be
identified or tested. On the other, a collection of rare
and extraordinary instances of sudden death which
have happened to be preceded by a powerful mental
impression, many of which bear clearly upon their
face the imprint of death by rupture of a blood-vessel,
heart failure, or paralysis, in the course of some well-
marked and clearly defined chronic disease, like val-
vular heart-mischief, diabetes, or Bright 's disease.

Upon investigation most of these cases which have
been seen by a physician previous to death have been
recognized as subjed: to a disease likely to terminate
in sudden death; and practically all in which a post-
mortem examination has been made have shown a
definite physical cause of death. The fright, anger,
or other mental impression, was merely the last straw,
which, throwing a sudden strain upon already weak-
ened vessels, heart, or brain, precipitated the final
catastrophe. In some cases, even the sense of fright
and the premonition of approaching death were merely
the first symptoms of impending dissolution.

The stories of death from purely imaginative impres-
sions, such as the victims being told that they were
seriously ill, that they would die on or about such and
such a date, fall into two great classes. The first of
these — involving death at a definite date, after it had
been prophesied either by the victim or some physician
or priest — may be dismissed in a few words, as they
lead at once into the realm of prophecy, witchcraft,
and voodoo. Most of them are little better than after-

416 PREVENTABLE DISEASES

echoes of the ethnic stories of the "evil eye," and of
bewitched individuals fading away and dying after
their wax image has been stuck full of pins or otherwise
mutilated. There have occurred instances of individ-
uals dying upon the date at which some one in whose
powers of prophecy they had confidence declared they
would, or even upon a date on which they had settled
in their own minds, and announced accordingly; but
these are so rare as readily to come within the percent-
age probabilities of pure coincidence. Most such pro-
phecies fail utterly; but the failures are not recorded,
only the chance successes.

The second group of these alleged instances of death
by mental impression is in most singular case. Prac-
tically every one with whom you converse, every popu-
lar volume of curiosities which you pick up, is ready to
relate one or more instances of such an event. But the
more you listen to these relations, the more familiar do
they become, until finally they practically simmer
down to two stock legends, which we have all heard
related in some form.

First, and most famous, is the story of a vigorous,
healthy man accosted by a series of doctors at succes-
sive corners of the street down which he is walking,
with the greeting : —

" Why, my dear Mr. So-and-So, what is the matter ?
How ill you look!"

He becomes alarmed, takes to his bed, falls into a
state of collapse, and dies within a few days.

The other story is even more familiar and dramatic.
Again it is a group of morbidly curious and spiteful

MENTAL INFLUENCE IN DISEASE 417

doctors who desire to see whether a human being can
be killed by the power of his imagination. A con-
demned criminal is accordingly turned over to them.
He is first allowed to see a dog bled to death, one of
the physicians holding a watch and timing the process
with, "Now he is growing weaker! Now his heart is
failing ! Now he dies ! " Then, after having been in-
formed that he is to be bled to death instead of guil-
lotined, his eyes are bandaged and a small, insignificant
vein in his arm is opened. A basin is held beneath his
arm, into which is allowed to drip and gurgle water
from a tube so as to imitate the sounds made by the
departing life-blood. Again the death-watch is set and
the stages of his decline are called off: "Now he
weakens ! Now his heart is failing !" until finally, with
the solemn pronouncement, " Now he dies ! " he falls
over, gasps a few times and is dead, though the total
amount of blood lost by him does not exceed a few
teaspoonfuls.

A variant of the story is that the trick was played for
pure mischief in the initiation ceremonies of some lodge
or college fraternity, with the horrifying result that
death promptly resulted.

The stories seem to be little more than pure creatures
of the same force whose power they are supposed to
illustrate, amusing and dramatic fairy-tales, handed
down from generation to generation from Heaven
knows what antiquity. Death under such circumstances
as these may have occurred, but the proofs are totally
lacking. One of our leading neurologists, who had ex-
tensively experimented in hypnotism and suggestion,

418 PREVENTABLE DISEASES

declared a short time ago : " I don't believe that death
was ever caused solely by the imagination."

Now as to the scope of this remedy, the extent of the
field in which it can reasonably be expected to prove
useful. This discussion is, of course, from a purely phy-
sical point of view. But it is, I think, now generally
admitted, even by most believers in mental healing,
that it is only, at best, in rarest instances that mental
influence can be relied upon to cure organic disease,
namely, disease attended by actual destruction of tissue
or loss of organs, limbs, or other portions of the body.
This limits its field of probable usefulness to the so-
called "functional diseases," in which — to put it
crudely — the body-machine is in apparently perfect
or nearly perfect condition, but will not work; and
particularly that group of functional diseases which is
believed to be due largely to the influence of the imagi-
nation.

Nowhere can the curious exaggeration and over-
estimation of the real state of affairs in this field be bet-
ter illustrated than in the popular impression as to the
frequency in actual practice of "imaginary" diseases.
Take the incidental testimony of literature, for instance,
which is supposed to hold the mirror up to nature, to
be a transcript of life. The pages of the novel are full,
the scenes of the drama are crowded with imaginary
invalids. Not merely are they one of the most valuable
stock properties for the humorist, but whole stories
and comedies have been devoted to their exploitation,
like Moliere's classic "Le Malade Imaginaire," and
"Le Medecin Malgre Lui." Generation after genera-

MENTAL INFLUENCE IN DISEASE 419

tion has shaken its sides until they ached over these
pompous old hypochondriacs and fussy old dowagers,
whose one amusement in life is to enjoy ill health and
discuss their symptoms. They are as indispensable
members of the dramatis persona of the stock company
of fiction as the wealthy uncle, the crusty old bachelor,
and the unprotected orphan. Even where they are only
referred to incidentally in the course of the story, you
are given to understand that they and their kind furnish
the principal source of income for the doctor; that if
he has n't the tact to humor or the skilled duplicity to
plunder and humbug these self-made sufferers, he might
as well retire from practice. In short, the entire atmo-
sphere of the drama gives the strong impression that
if people — particularly the wealthy classes — would
shake themselves and go about their business, two-thirds
of the illness in the world would disappear at once.

Much of this may, of course, be accounted for by
the delicious and irresistible attractiveness, for literary
purposes, of this type of invalid. Genuine, serious ill-
ness, inseparable from suffering and ending in death,
is neither a cheerful, an interesting, nor a dramatic
episode, except in very small doses, like a well-staged
deathbed or a stroke of apoplexy, and does not furnish
much valuable material for the novelist or the play-
writer. Battle, murder, and sudden death, while hor-
rible and repulsive, can be contemplated with vivid,
gruesome interest, and hence are perfectly available
as interest producers. But much as we delight to talk
about our symptoms, we are never particularly inter-
ested in listening to those of others, still less in seeing

420 PREVENTABLE DISEASES

them portrayed upon the stage. On account of their
slow course, utter absence of picturesqueness, and de-
pressing character, the vast majority of diseases are
quite unsuitable for artistic material. In fact, the lit-
erary worker is almost limited to a mere handful, at
one extreme, which will produce sudden and dramatic
effects, like heart failure, apoplexy, or the ghastly
introduction of a "slow decline" for a particularly
pathetic effect; and at the other extreme, those im-
aginary diseases, migraines and vapors, which furnish
amusement by their sheer absurdity.

Be that as it may, such dramatic and literary ten-
dencies have produced their effect, and the popular
impression of the doctor is that of a man wrho spends
his time between rushing at breakneck speed to save
the lives of those who suddenly find themselves in
articulo mortis and will perish unless he gets there
within fifteen minutes, and dancing attendance upon a
swarm of old hypochondriacs, neurotics, and nervous
dyspeptics, of both sexes. As a matter of fact, these
two supposed principal occupations of the doctor are
the smallest and rarest elements in his experience.

A few years ago a writer of world-wide fame de-
liberately stated, in the course of a carefully considered
and critical discussion of various forms of mental heal-
ing, that it was no wonder that these methods excited
huge interest and wide attention in the community,
because, if valid, they would have such an enormous
field of usefulness, seeing that at least seven-tenths
of all the suffering which presented itself for relief to
the doctor was imaginary.

MENTAL INFLUENCE IN DISEASE 421

This, perhaps, is an extreme case, but is not far from
representing the general impression. If a poll were to
be taken of five hundred intelligent men and women
selected at random, as to how much of the sufferings of
all invalids, or sick people who are not actually ob-
viously "sick unto death" or ill of a fever, was real
and how much imaginary, the estimate would come
pretty close to an equal division. But when one comes
to try to get at the actual facts, an astonishingly differ-
ent state of affairs is revealed. I frankly confess that
my own awakening was a matter of comparatively
recent date.

A friend of mine was offered a position as consulting
physician to a large and fashionable sanatorium. He
hesitated because he was afraid that much of his time
would be wasted in listening to the imaginary pains,
and soothing the baseless terrors, of wealthy and fash-
ionable invalids, who had nothing the matter with
them except — in the language of the resort — " ner-
vous prosperity." His experience was a surprise. At
the end of two years he told me that he had had under
his care between six and seven hundred invalids, a
large percentage of whom were drawn from the wealth.-
ier classes; and out of this number there were only
jive whose sufferings were chiefly attributable to their
imagination. Many of them, of course, had compara-
tively trivial ailments, and others exaggerated the de-
gree or mistook the cause of their sufferings; but the
vast majority of them were, as he naively expressed it,
"really sick enough to be interesting."

This set me to thinking, and I began by making a

422 PREVENTABLE DISEASES

list of all the "imaginary invalids" I had personally
known, and to my astonishment raked up, from over
twenty years' medical experience, barely a baker's
dozen. Inquiries among my colleagues resulted in a
surprisingly similar state of affairs. While most of
them were under the general impression that at least
ten to twenty per cent of the illnesses presenting them-
selves were without substantial physical basis and
largely imaginary in character, when they came actually
to cudgel their memories for well-marked cases and to
consult their records, they discovered that their memo-
ries had been playing the same sort of tricks with them
that the dramatists and novelists had with popular
impressions.

Within the past few months one of the leading
neurologists of New York, a man whose practice is
confined exclusively to mental and nervous diseases,
stated in a public address that purely or even chiefly
imaginary diseases were among the rarer conditions
that the physician was called upon to treat. Shortly
after, two of the leading neurologists of Philadelphia,
one of them a man of international reputation, practi-
cally repeated this statement ; and they put themselves
on record to the effect that the vast majority of those
who imagined themselves to be ill were ill, though
often not to the degree or in precisely the manner that
they imagined themselves to be.

Obviously, then, this possible realm of suffering in
which the mind can operate is very much more limited
than was at one time believed. In fact, imaginary dis-
eases might be swept out of existence, and humanity

MENTAL INFLUENCE IN DISEASE 423

would scarcely know the difference, so little would
the total sum of its suffering be reduced.

Another field in which there has been much general
misunderstanding and looseness of both thought and
statement, which has again led to exaggerated ideas
of the direct influence of the mind over the body, is
the well-known effect of emotional states, such as
fright or anger, upon the ordinary processes of the
body. Instances of this relation are, of course, house-
hold words, — the 'man whose " hair turned white in
a single night" from grief or terror; the nursing mother
who flew into a furious^fit of passion and whose child
was promptly seized with convulsions and died the
next time it was put to the breast; the father who is
prostrated by the death or disgrace of a favorite son,
and dies within a few weeks of a broken heart. The
first thing that is revealed by even a brief study of this
subject is that these instances are exceedingly rare, and
owe their familiarity in our minds to their striking and
dramatic character and the excellent " material " which
they make for the dramatist and the gossip. It is even
difficult to secure clear and valid proof of the actual
occurrence of that sudden blanching of the hair, which
has in the minds of most of us been accepted from our
earliest recollection.

More fundamental, however, and vital, is the extent
to which we have overlooked the precise method in
which these violent emotional impressions alter bodily
activities, like the secretions. Granting, for the sake
of argument, that states of mind, especially of great
tension, have some direct and mysterious influence as

424 PREVENTABLE DISEASES

such, and through means which defy physical recog-
nition and study, it must be remembered that they
have a perfectly definite physiological sphere of influ-
ence upon vital activities. Indeed, we are already in
a position to explain at least two-thirds of these so-
called "mental influences" upon purely physical and
physiological grounds.

First of all, we must remember that these emotions
which we are pleased to term "states of mind" are
also states of body. If any man were to stand up before
you, for instance, either upon the stage or in private,
and inform you that he was " scared within an inch of
his life," without tremor in his voice, or paling of his
countenance, or widening eyes, or twitching muscles,
or preparations either to escape or to fight, you would
simply laugh at him. You would readily conclude,
either that he was making fun of you and felt no such
emotion, or that he was repressing it by an act of mi-
raculous self-control. The man who is frightened and
does n't do anything or look as if he were going to do
anything, the man who is angry and makes no move-
ment or even twitching suggesting that fact, is neither
angry nor frightened.

An emotional state is, of course, a peculiarly com-
plex affair. First, there is the reception of the sensa-
tion, sight, sound, touch, or smell, which terrifies.
This terror is a secondary reaction, and in ninety-nine
cases out of a hundred is conditioned upon our mem-
ory of previous similar objects and their dangerousness,
or our recollection of what we have been told about their
deadliness. Then instantly, irrepressibly, comes the

MENTAL INFLUENCE IN DISEASE 425

lightning-flash of horror to our heart, to our muscles,
to our lungs, to get ready to meet this emergency.
Then, and not till then, do we really feel the emotion.
In fact, our most pragmatic philosopher, William
James, has gone so far as to declare that emotions are
the after-echoes of muscular contractions. By the
time an emotion has fairly got us in its grip so that we
are really conscious of it, the blood-supply of half the
organs in our body has been powerfully altered, and
often completely reversed.

To what extent muscular contractions condition
emotions, as Professor James has suggested, may be
easily tested by a quaint and simple little experiment
upon a group of the smallest voluntary muscles in the
body, those that move the eyeball. Choose some time
when you are sitting quietly in your room, free from all
disturbing thoughts and influences. Then stand up and,
assuming an easy position, cast the eyes upward and
hold them in that position for thirty seconds. Instantly
and involuntarily you will be conscious of a tendency
toward reverential, devotional, contemplative ideas
and thoughts. Then turn the eyes sideways, glancing
directly to the right or to the left, through half-closed
lids. Within thirty seconds images of suspicion, of
uneasiness, or of dislike, will rise unbidden in the mind.
Turn the eyes to one side and slightly downward, and
suggestions of jealousy or coquetry will be apt to spring
unbidden. Direct your gaze downward toward the
floor, and you are likely to go off into a fit of reverie
or of abstraction.

In fact, as Darwin long ago remarked, quoting in

426 PREVENTABLE DISEASES

part from Bain: "Most of our emotions [he should
have said all] are so closely connected with their ex-
pression that they hardly exist if the body remains
passive. As Louis XVI, facing a mob, exclaimed,
'Afraid? Feel my pulse!' so a man may intensely
hate another, but until his bodily frame is affected
he can hardly be said to be enraged."

And, a little later, from Maudsley: —

"The specific muscular action is not merely an ex-
ponent of passion, but truly an essential part of it.
If we try, while the features are fixed in the expression
of one passion, to call up in the mind a different one,
we shall find it impossible to do so."

It will also be recollected what an important part
in the production of hypnosis and the trance state, fixed
and strained positions of these same ocular muscles
have always been made to play. Many hypnotists can
bring their subjects under their influence solely by
having them gaze fixedly at some bright object like a
mirror, or into a crystal sphere, for a few minutes or
even seconds.

A graphic illustration of the importance of muscu-
lar action in emotional states is the art of the actor.
Not only would it be impossible for an actor to make
an audience believe in the genuineness of his supposed
emotion if he stood glassy-eyed and wooden-limbed
declaiming his lines in a monotone, without gestures
or play of expression of any sort, but it would also be
impossible for him to feel even the counterfeit sensa-
tion which he is supposed to represent. So definite and
so well recognized is this connection, that many actors

MENTAL INFLUENCE IN DISEASE 427

take some little time, as they express it, to " warm up "
to their part, and can be visibly seen working themselves
up to the pitch of emotion desired for expression by
twitching muscles, contractions of the countenance,
and catchings of the breath. This last performance,
by the way, is not by any means confined to the stage,
but may be seen in operation in clashes and disagree-
ments in real life. An individual who knows his
case to be weak, or himself to be lacking in determina-
tion, can be seen working himself up to the necessary
pitch of passion or of obstinacy. There is even a lovely
old fairy-tale of our schoolboy days, which is still to
be found in ancient works on natural history, to the
effect that the King of Beasts himself was provided
with a small, horny hook or spur at the end of his tail,
with which he lashed himself into a fury before spring-
ing upon his enemy!

What, then, will be the physical effect of a shock or
fright or furious outburst of anger upon the vital se-
cretions ? Obviously, that any processes which require
a full or unusually large share of blood-supply for their
carrying out will be instantly stopped by the diversion
of this from their secreting cells, in the wall of the
stomach, in the liver, or in the capillaries of the brain,
to the great muscular masses of the body, or by some
strange, atavistic reflex into the so-called "abdominal
pool," the portal circulation. The familiar results are
just what might have been expected. The brain is so
suddenly emptied of blood that connected thought
becomes impossible, and in extreme cases we stand as
one paralyzed, until the terror that we would flee from

428 PREVENTABLE DISEASES

crashes down upon us, or we lose consciousness and
swoon away. If the process of digestion happens to be
going on, it is instantly stopped, leaving the food to
ferment and putrefy and poison the body-tissues which
it would otherwise have nourished. The cells of the
liver may be so completely deprived of blood as to stop
forming bile out of broken-down blood pigment, and
the latter will gorge every vessel of the body and escape
into the tissues, producing jaundice.

Every one knows how the hearing of bad news or
the cropping up of disagreeable subjects in conversa-
tion at dinner-time will tend to promote indigestion in-
stead of digestion. The mechanism is precisely similar.
The disagreeable news, if it concern a financial or ex-
ecutive difficulty, will cause a rush of blood to the brain
for the purpose of deciding what is to be done. But
this diminishes the proper supply of blood to the stom-
ach and to the digestive glands, just as really as the
paralysis of violent fright or an explosion of furious
anger. If the unpleasant subject is yet a little more
irritating and personal, it will lead to a corresponding
set of muscular actions, as evidenced in heightened
color, loud tones, more or less violent gesticulation,
with marked interruption of both mastication and the
secretion of saliva and all other digestive juices. In
short, fully two-thirds of the influences of emotional
mental states upon the body are produced by their
calling away from the normal vital processes the blood
which is needed for their muscular and circulatory
accompaniments. No matter how bad the news or how
serious the danger, if they fail to worry us or to frighten

MENTAL INFLUENCE IN DISEASE 429

us, — in other words, to set up this complicated train
of muscular and blood-supply changes, — then they
have little or no effect upon our digestions or the me-
tabolism of our liver and kidneys.

The classic "preying upon the damask cheek" of
grief, and the carking effect of the Black Care that rides
behind the horseman, have a perfectly similar physical
mechanism. While the primary disturbance of the
banking balances of the body is less, this is continued
over weeks and months, and in addition introduces
another factor hardly less potent, by interfering with all
the healthful, normal, regular habits of the body, —
appetite, meal- times, sleep, recreation. These wastings
and pinings and fadings away are produced by mental
influence, in the sense that they cannot be cured by
medicines or relieved at once by the best of hygienic
advice ; but it is idle to deny that they have also a broad
and substantial physical basis, in the extent to which
states of emotional agony, despair, or worry interfere
with appetite, sleep, and proper exercise and recreation
in the open air. Just as soon as they cease to interfere
with this normal regularity of bodily functions, the
sufferer begins to recover his health.

We even meet with the curious paradox of individuals
who, though suffering the keenest grief or anxiety over
the loss or serious illness of those nearest or dearest to
them, are positively mortified and ashamed because
their countenances show so little of the pallid hues and
the haggard lines supposed to be inseparably associated
with grief. So long as the body-surplus is abundant
enough to stand the heavy overdrafts made on it by

430 PREVENTABLE DISEASES

grief and mental distress, without robbing the stomach
of its power to digest and the brain of its ability to sleep,
the physical effects of grief, and even of remorse, will
be slight.

It must be remembered that loss of appetite is not
in itself a cause of trouble, but a symptom of the stom-
ach's inability to digest food ; in this instance, because
it finds that it can no longer draw upon the natural
resources of the body in sufficient abundance to carry
out its operations. The state is exactly like a tightness
of the money market, when, on account of unnatural
retention or hoarding in some parts of the financial
field, the accumulation of sufficient amounts of float-
ing capital at the banks for moving the crop or paying
import duties cannot be carried out as usual. The vital
system is, in fact, in a state of panic, so that the stomach
cannot get the temporary credit or capital which it
requires .

A similar condition of temporary panic, call it mental
or bodily, as you will, occurs in disease and is not con-
fined to the so-called imaginary diseases, or even to the
diseases of the nervous system, but is apt to be present
in a large number of acute affections, especially those
attended by pain. Sudden invasion of the system by the
germs of infectious diseases, with their explosions of
toxin-shells all through the redoubts of the body, often
induces a disturbance of the bodily balance akin to
panic. This is usually accompanied and aggravated by
an emotional dread and terror of corresponding inten-
sity. The relief of the latter, by the confident assur-
ance of an expert and trusted physician that the chances

MENTAL INFLUENCE IN DISEASE 431

are ten to one that the disease will run its course in a
few days and the patient completely recover, — es-
pecially if coupled with the administration of some
drug which relieves pain or diminishes congestion in
the affected organs, — will often do much toward re-
storing balance and putting the patient in a condition
where the natural recuperative powers of the system
can begin their work. The historic popularity of opium,
and of late of the coal-tar products (phenacetine and
acetanilide) , in the beginning of an acute illness, is
largely based on the power which they possess of dull-
ing pain, relieving disturbances of the blood-balance,
and soothing bodily' and mental excitement. Fever-
panic or pain-panic, like a banking panic, though it
has a genuine and substantial basis, can be dealt with
and relieved much more readily after checking ex-
cessive degrees of distrust and excitement. An opiate
will relieve this physical pain-panic, just as a strong
mental impression will relieve the fright-paralysis and
emotional panic which often accompany it, and thus
give a clearer field and a breathing space for the more
slowly acting recuperative powers of nature to assert
their influence and get control of the situation.

But neither of them will cure. The utmost that they
can do is to give a breathing spell, a lull in the storm,
which the rallying powers of the body, if present, can
take advantage of. If the latter, however, be not ade-
quate to the situation, the disease will progress to
serious or even fatal termination, just as certainly as
if no such influence had been exerted, and often at an
accelerated rate. In fact, our dependence upon opiates

432 PREVENTABLE DISEASES

and mental influence have been both a characteristic
and a cause of the Dark Ages of medicine. The more
we depended upon these, the more content we were
to remain in ignorance of the real causes of disease,
whether bodily or mental.

The second physical effect produced by mental in-
fluence is probably the most important of all, and that
is the extent to which it induces the patient to follow
good advice. We as physicians would be the last to
underestimate the importance of the confidence of our
patients. But we know perfectly well that our retention
of that confidence will depend almost entirely upon the
extent to which we can justify it; that its principal
value to us lies in the extent to which it will insure
prompt obedience to our orders, and intelligent and
loyal cooperation with us in our fight against disease.
The man who would depend upon the confidence of
his patients as a means of healing, would soon find
himself without practice. We know by the bitterest of
experience that no matter how absolute and boundless
the confidence of our patients may be in our ability
to heal them, no matter how much they may express
themselves as cheered and encouraged by our presence,
ninety-nine per cent of the chance of their recovery de-
pends upon the gravity of the disease, the vigor of their
powers of resistance, and our skill and intelligence in
combating the one and assisting the other.

Valuable and helpful as courage and confidence in
the sick-room are, they are but a broken reed which will
pierce the hand of him who leans upon it too heavily,
be he patient or physician. We can all recall, as among

MENTAL INFLUENCE IN DISEASE 433

our saddest and most heart-breaking experiences, the
cases of fatal disease, which were well-nigh hopeless
from the start, and yet in which the sufferers expressed,
and maintained to the last moments of conscious speech,
a bright and pathetically absolute confidence in our
powers of healing, based upon our success in some
previous case, or upon their own irrepressible hope-
fulness.

Even the deadliest and most serious of infectious
diseases, consumption, has — as is well known — as
one of its prominent symptoms an irrepressible hope-
fulness and confidence that they will get well, on the
part of a considerable percentage of its victims. This
has even been formally designated in the classical
medical treatises as the " Spes Phthisical or "Con-
sumptive Hope." But these hopeful consumptives die
just as surely as the depressed ones ; in fact, if anything,
in a little larger proportion. It well illustrates the other
side of the shield of hope and confidence, the danger
of unwavering expectancy, in that it is chiefly those
who are early alarmed and turn vigorously to fight
the disease under intelligent medical direction, who
make the recoveries. Too serene a courage, too pro-
found a confidence in occult forces, is only a form of
fatalism and a very dangerous one.

Broadly speaking, mental states in the sick-room
are a pretty fair index — I don't mind saying, prod-
uct — of bodily states. Hopefulness and confidence
are usually favorable signs, for the reason that they
are most likely to be displayed by individuals who, al-
though they may be seriously ill, are of good physique,

434 PREVENTABLE DISEASES

have high resisting power, and will make a successful
fight against the disease. So, roughly speaking, cour-
age and hopefulness are good omens, on purely physi-
cal grounds.

But these are only rough indications of probabili-
ties, not reliable signs ; and as a rule we are but little
affected by either the hopes or the fears of our patients
in making up our estimate of their chances. The only
mental symptom that weighs heavily with us is indif-
ference. This puts us on the lookout at once. So long
as our patients have a sufficiently vivid and lively fear
of impending death, we feel pretty sure that they are
not seriously ill ; but when they assure us dreamily that
they " feel first-rate," forget to ask us how they are
getting along, or become drowsily indifferent to the
outlook for the future, then we redouble our vigilance,
for we fear that we recognize the gradual approach of
the Great Restbringer, the merciful drowsiness which
in nine cases out of ten precedes and heralds the coming
of the Long Sleep.

Lastly, the cases in which the sufferings of the patient
are due chiefly to a morbid action of his or her imagi-
nation, are a small percentage of the total of the ills
which come before us for relief. But, even of this
small percentage, only a very few are in perfect or even
reasonably good physical health. A large majority of
even these neurasthenics, psychasthenics, imaginary
invalids, and bodily or mental neurotics, have some phy-
sical disturbance, organic or functional, which is the
chief cause of their troubles. And the important point
is that our success in relieving these sufferers will de-

MENTAL INFLUENCE IN DISEASE 435

pend upon our skill in ferreting out this physical basis,
and the extent to which we can succeed in correcting
or relieving it. We no longer ridicule or laugh at these
unfortunates. On the contrary we pity them from the
bottom of our hearts, because we know that their suf-
ferings, however polarly remote they may be from
endangering their lives in any way, and however imagi-
nary in a purely material sense, are to them real. Their
happiness is destroyed and their efficiency is crippled
just as genuinely and effectively as if they had a broken
limb or a diseased heart.

We are now more and more firmly convinced that
these patients, however ludicrously absurd their fore-
bodings, are really sick, either bodily or mentally,
and probably both. A perfectly healthy individual
seldom imagines himself or herself to be ill. And as the
list of so-called functional diseases — that is to say,
those diseases in which no definite, objective mark of
degeneration or decay in any tissue or organ can be
discovered — are steadily and swiftly diminishing
under the scrutiny of the microscope and the methods
of the laboratory, so these purely imaginary diseases,
these " depressed mental states," these "essential mor-
bid tendencies," are also rapidly diminishing in num-
ber, as cases are more conscientiously and personally
studied and worked out.

Even hysteria is no longer looked upon as sheer per-
versity on the part of the patient, but is patiently traced
back, stage by stage, until if possible the primary
"strangulated emotion" which caused it is discovered;
and where this can be found the whole morbid ten-

436 PREVENTABLE DISEASES

dency can often be relieved and reversed Almost as if
by magic.

To sum up : My contention is, that the direct influ-
ence of emotional states upon bodily organs and func-
tions has been greatly exaggerated ; that it is exceedingly
doubtful whether, for instance, any individual in a
reasonable condition of health was ever killed by an
imaginary or even an emotional shock; that there is
surprisingly little valid evidence that the hair of any
human being turned white in a single night, or was
completely shed within a few hours, under the influ-
ence of fright, terror, or grief; that the effects upon
bodily functions and secretions, digestion, etc., pro-
duced by emotion, are due to secondary effects of the
latter, diverting the energy of the body into other
channels and disturbing the general balance of its
forces and blood-supply ; that the actual percentage of
cases in which the imagination plays the chief, or even
a dominant part, is small, probably not to exceed five
or ten per cent; that a very considerable share of the
influence of mental impressions in the cure of disease
is due to the relief of mental panic, permitting the
rallying of the recuperative powers of the body, and
to the extent to which they produce the reform of bad
physical habits or surroundings or conditions.

The most important element in the cure of disease
by mental impression is time plus the vis medicatrix
naturce. The mental impression — suggestion, scold-
ing, securing of confidence — diverts the attention of
the patient until his own recuperative power and the
intelligent correction of bad physical habits remedy

MENTAL INFLUENCE IN DISEASE 437

I

his defect. Pure mental impression, however vivid,
which is not followed up by improvement of the en-
vironment, or correction of bad physical habits, will
be almost absolutely sterile. Faith without works
is as dead in medicine as in religion. Mental influence
is little more than an introduction committee to real
treatment. Even the means used for producing mental
impressions are physical, — impressions made upon
some one of the five senses of the individual. In short,
as Barker aptly puts it, " Every psychotherapy is also
a physical therapy."

Furthermore, even mental worry, distress, or de-
pression, in nine cases' out of ten has a physical cause.
To remedy conditions of mental stress by correcting
the underpay, overwork, bad ventilation, or under-
feeding on account of illness or death of the wage-
earner of the family, is, of course, nothing but the most
admirable common sense; but to call it the mental
treatment of disease is a mere juggling with words.
" Take care of the body and the mind will take care of
itself," is a maxim which will prove valid in actual
practice nine times out of ten.

INDEX

ABEBNETHY, DR. JOHN, 80.

Acne, 38.

Acromegaly, 119.

Adenoids, 105-122.

Air, foul, 97.

Alimentary canal, 274-279.

Allbutt, Sir Clifford, 134.

Allen, Dr. Harrison, 120.

Animals, immune to certain dis-
eases, 255.

Anti-bodies. See Antitoxins.

Antisepsis, 333, 336-339.

Antitoxins, or anti-bodies, &, 93,
94, 199, 200 ; discovery and use
of the diphtheria antitoxin,
230-233, 236, 242, 401; te-
tanus antitoxin, 345, 346, 398.

Apoplexy, 40, 402.

Appendicitis, 269-288.

Appendix, vermiform, 35, 36,
268-270, 273-279.

Asepsis, 333.

Asthmatics, 328.

Attitude, the upright, 76.

Autointoxication, 376.

Bacilli. See Bacteria.

Bacteria, abundance of, in the

body, 10, 99.
Bang, Professor, 148.
Bath, the cold, 98.
Bile, in vomiting, 379.
Bites, danger from, 342.
Blood, coagulation of, 39, 40.
Blood-corpuscles, 24-29.
Blood-poisoning, 331-349.
Bloodgood, Dr. J. C., 272.
Bones, nature of, 20, 21.
Boswell, James, 88.
Bridge, Dr. Norman, 95.

Caecum, 274-278.

Cancer, a rebellion of the cells,

42, 351 ; heredity and, 50, 51 ;
individuality of, 350 ; probable
nature of, 351 ; death-rate from,
352, 353; natural history of,
353-364 ; not communicable,
357, 358; vain search for a
parasite, 359, 360 ; a disease of
senility, 363, 364 ; problems of
prevention and cure, 365, 366.

Carriage, in illness, 76.

Cattani, 398.

Cellular theory of disease, 18, 19.

Cerebro-spinal meningitis, 397.

Chantemesse, 221.

Children's diseases, importance
of, 243-245; prevention of,
245 ; dangerous results of, 245,
246; effect on growth and de-
velopment, 247; reasons for,
248-250 ; occasional severity
of, 251-254; taming of, 253,
254; causes of, 254, 255; treat-
ment of, 255, 256; symptoms
of, 256, 257; the three chief,
257-266.

Cities, disease and death-rate in,
159-165.

Civilization, and nervousness,
406-408.

Cleanliness, 98.

Cohnheim, 364.

Colds, treatment of, 11, 12, 93-
101; cause of, 85-93; how to
catch, 101, 102; their relation
to rheumatism, 320, 321, 323,
324, 326, 327.

Colic, 4.

Color, in diagnosis, 70-74.

Congenital disease, 44, 45.

Coughing, use of, 11, 12.

Darwin, Charles, quoted, 425,
426.

440

INDEX

Diagnosis, 55-82.

Diarrhoea, use of, 5 ; treatment of,
5.

Diphtheria, 222-242; attacking
the nervous system, 400, 401.

Disease, causes of, 3; not abso-
lute but relative, 14 ; former
conceptions of, 15-18; organic
and functional, 405,406; men-
tal influence in, 411-437.

Drafts, 94, 95, 99.

Earache, 110.
Edison, Thomas A., 286.
Epilepsy, heredity and, 52, 53.
Erysipelas, 348.
Eustachian tubes, 109, 110.
Expectoration, 142, 143.
Eye-strain, 377.

Facial expression, in diagnosis,
62-70.

Fever, meaning of, 7, 8; treat-
ment of, 8-11.

Flick, Dr. Laurence, 96.

Fly, house, and typhoid, 210, 211.

Food-tube, the, 274-279.

Gait, in illness, 76-78.

Gall-bladder, 37.

Grip, the, 90.

Guinea-pig, a burnt offering,
222; used in the discovery of
the diphtheria antitoxin, 229-
231.

Hand, the, in diagnosis, 73-75.

Harelip, 37.

Headache, purpose and meaning
of, 12, 13, 367-376 ; treatment
of, 370, 371, 381-386; from
eye-strain, 377, 386; from di-
gestive disturbances, 377, 378 ;
sick headache, 378, 379, 381;
from stuffy rooms, 380; from
sluggish bowels and kidney
trouble, 380 ; from loss of sleep,
380, 381 ; from nasal obstruc-
tion, 381 ; rest the cure for, 382-
384 ; massage for the relief of,

385, 386 ; the nerves affected in,

385, 386.
Heart, effect of rheumatism on,

314, 315.
Heredity, in health and disease,

32-54.
Hernia, 36.

Holmes, Oliver Wendell, 125.
Horses, and disease, 344, 345.
Hospitals, blood-poisoning and

antisepsis in, 335-339.
Humoral theory of disease, 17, 18.
Huxley, Thomas Henry, quoted,

1, 112, 201.
Hysteria, 403, 406, 407, 435.

Imaginary illness, 415-422, 436.

Immunity, 93.

Indians, epidemics among, 251,
252.

Indifference of the dying, 434.

Infants, diagnosis in the case of,
81, 82.

Influenza, 90.

Insanity, heredity and, 52-54;
among savages and in civiliza-
tion, 408, 409; treatment of,
411, 412.

Intestines, 274.

James, William, 425.
Johnson, Samuel, 89.
Joints, diseases of, 318, 319.

King, Dr. Albert F. A., 298.
Koch, Robert, 126, 152, 153, 155,
156, 228, 308.

Laveran, 295.
Lister, Lord, 332.
Liver, functions of, 6, 7.
Lockjaw, 344-346, 397, 398.
Locomotor ataxia, 399; diagnosis

of, 77, 78.
Lungs, their liability to disease,

175-178.
Lupus, 126.

Malaria, 289-310.
Measles 243, 246, 248-252, 260-
263.

INDEX

441

Medicines, repulsive, 17.
Meningitis, 399, 400. See also

Cerebro-spinal meningitis.
Mental influence in disease, 411-

437

Metschnikoff, Elie, 214.
Meyer, William, 105.
Mind, its relation to the body,

390, 391, 411-437.
Mosquitoes, and malaria, 297-

307.

Mouth-breathing, 103-119.
Moxon, the pathologist, 187.
Mumps, 252.

Nails, the, in disease, 74, 75;
pus-germs lurking under, 334,
336, 349.

Nature, as a physician, 2, 3; not
to be trusted too blindly*1 7;
cooperating with, 9.

Nerves, affected in headache,
385, 386; old notions of, 387,
388; reality of, 389, 390; func-
tion of, 390 ; their diseases due
to morbid changes in their tis-
sues, 391, 392; affected by the
bodily condition, 393-395 ;
causes of disturbances in, 395-
397; diseases that attack them
directly, 397, 398; late effects
of other diseases on, 398-401 ;
nervousness and, 401-408 ;
death-rate from diseases of,
409, 410.

Nervousness, 403-408.

Neurasthenia, 401, 402.

Nocard, the veterinary patholo-
gist, 157.

Northrup, Dr. William, 196.

Noses, narrow, 118, 119.

Operations. See Surgery.
Opiates, 431, 432.
Osier, Dr. William, 160, 282.
Ovariotomy, 336.

Pain, nature's command to halt,
13, 382; nature's automatic
regulator, 383.

Paresis, 399.

Pimples, 38.

Pituitary body, 119.

Pneumonia, cause of, 84, 85, 88,
178-183, 185, 186 ; easily recog-
nized, 174, 175 ; recent increase
of, 184, 186; habits of the
pneumococcus, 186-191 ; its re-
lations to age and to other dis-
eases, 192-194; symptoms of,
194, 195; treatment of, 195,
196; outlook as to, 196, 197.

Poisons in the body, elimination
of, 3-13; from fatigue, 373-
376.

Psychotherapy, 413.

Pus, 331-336; germs of, 339-344,
346-349.

Pyaemia, 346.

Quinine, 293, 294.

Repair of the body in the lower

animals, 41, 42.
Rheumatism, 311-330.
Ross, Dr. Ronald, 247.

Savages, nervousness among, 407,

408.

Scarlet fever, 243, 247, 257-260.
Sciatica, cure of a case of, 389,

390.

Sclerosis, lateral, 399.
Scrofula, 126.
Seasickness, 379.
Senn, Dr. Nicholas, 357.
Septicaemia, 346.
Sleeping porches, 96, 97.
Smallpox, 125, 255.
Smell, 111.
Spitting, 142, 143.
Staphylococcus, 339, 340, 343,

348. See also Pus.
Sticking-plaster, 343.
Stomach, 274.
Streptococcus, 339-341, 348. See

also Pus.
Surgery, and blood-poisoning,

331-339.
Syphilis congenital 44; organ-

442

INDEX

ism of, -255, 399; attacking the
nervous system, 399.

Tait, Lawson, 336.

Taste, 111.

Teeth, crowded, 114, 115.

Tetanus, 344-346, 397, 398.

Tonsillitis, 320, 323, 324.

Tonsils, 107-109, 116-118.

Tooth, wisdom, 36, 37.

Tuberculosis, congenital, 45 ;
seeming inheritance of, 46-50 ;
diagnosis of, 68, 72; discovery
of the bacterial nature of, 123-
126; means of fighting, 127,
128; treatment of, 129-132;
prevention of, 132, 135-139;
universality of, 133, 134; pre-
vention of transmissionlof, 140-
145; in cattle and other ani-
mals, 146, 158; encouraging
outlook as to, 159-166; civili-
zation and, 166-173 ; cerebral
complications from, 399 ; hope-
fulness in, 433.

Tumor, Jensen's, 358, 362.

Typhoid fever, 199-221.
Typhus, 203, 204.

Uric acid, 327, 328.

Vestigia, 35-39, 268, 260.
Virchow, Rudolf, 18.
Vis medicatrix naturae, 2.
Voice, in diagnosis, 78.
Voltaire, on doctors, 14.
Vomiting, use of, 4, 5; from

headache and seasickness, 378,

379; bile in, 379.

Waters, mineral, 17.
Whooping-cough, 244, 246, 249,

263-266.

Williams, Dr. Leonard, 93.
Williams, Dr. Roger, 364.
Wound-fever, among soldiers,

347.
Wounds, healing of, 40, 41;

blood-poisoning in, 331-335,

341-344; treatment of, 342-

344, 346.
Wright, Dr., 221.

(STfre

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